# Paramedics Often Fail to Give Epinephrine for Anaphylaxis



## OfficerEvenEMT (Nov 20, 2012)

From: http://www.medscape.com/viewarticle/774828



> Of the 52 patients with anaphylaxis, 25 (48.1%) were given oxygen, 8 (15.4%) were given epinephrine, 6 (11.5%) were given intravenous fluids, 10 (19.2%) were given albuterol, and 13 (25.0%) were given methylprednisolone. The majority (42; 80.8%) were given diphenhydramine.
> 
> "It is apparent from these results that paramedic education in the use of epinephrine for allergic reactions and anaphylaxis needs to be implemented. We have done that since we collected these data," Dr. El Sanadi noted.



It looks like paramedics are giving the wrong medication when it comes to anaphylaxis. Whaddya all think?


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## ffemt8978 (Nov 20, 2012)

FYI - Medscape requires a login to view the entire article/study.


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## Aidey (Nov 20, 2012)

I don't see any wrong medications. There is a difference between not being aggressive with epi and an incorrect med. All of the medications listed are indicated in anaphylaxis.


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## OfficerEvenEMT (Nov 20, 2012)

Aidey said:


> I don't see any wrong medications. There is a difference between not being aggressive with epi and an incorrect med. All of the medications listed are indicated in anaphylaxis.



It further says:



> "Epinephrine is the first treatment — not [diphenhydramine], not steroids — because epinephrine works fast and reverses the anaphylactic reaction in about 30 seconds. [Diphenhydramine] doesn't work for...almost an hour. For some reason, people are afraid to use it, perhaps because it is an injection, but they shouldn't be because it is the treatment of choice. Why wouldn't you use the 30 second drug if a patient is having a life-threatening reaction?"



It seems that the diphenhydramine is the wrong med to use as it takes too long, but epi is the right med to use because it's effect is so quick. Whaddya think?


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## MediMike (Nov 20, 2012)

I'd like to be able to read the whole article, and see what exact determining factors they use to denote "anaphylaxis".  Since you have access to it would you mind looking through it and throwing out their criteria?


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## mycrofft (Nov 21, 2012)

I've seen benedryl IV work a lot faster than an hour, and epi doesn't reverse the reaction, it staves it off for a little while. We used to use Susphrine to get the fast onset then longer results than regular epi, but if there was an issue or there was too much Susphrine, then we had cauised another problem.


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## Medic Tim (Nov 21, 2012)

I know a number of areas that have strict protocols for when epi is given /what qualifies as anaphylaxis vs severe allergic reaction. I have heard of a system that required a sys bp of 90 or less for epi to be given regardless of pt presentation and others vitals/signs/symptom. The places I have worked, management/cqi/medical director feel that it is overtreated and that providers are to quick to jump to epi when it is not needed.


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## VFlutter (Nov 21, 2012)

Where is that data from? Also, did they define how they qualified anaphylaxis? Maybe some of the cases were borderline and not considered to be immediately life threatening to the medics.


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## bigbaldguy (Nov 21, 2012)

ChaseZ33 said:


> not considered to be immediately life threatening to the medics.



of course it's not, the patients the one with the problem


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## OfficerEvenEMT (Nov 21, 2012)

The source is:

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract 58. Presented November 12, 2012.


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## silver (Nov 21, 2012)

How did they determine that the patients met the diagnostic criteria of anaphylaxis initially? Or are they retrospectively looking at diagnosis in ED?


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## leoemt (Nov 21, 2012)

Here in WA Basics can give Epi for Anaphalaxis. 

Per King County Protocol, signs and symptoms must be Respiratory Distress and Hypotension. If we give an Epi Pen we need to get ALS on scene or get patient to the doctor. 

http://www.emsonline.net/assets/EMTPatientCareProtocols2012.pdf


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## Veneficus (Nov 21, 2012)

I read the study.

It is deeply flawed, based on protocol and not patient presentation is just one problem.

It will carry no weight in my future clinical decisions or opinions on EMS.


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## mycrofft (Nov 21, 2012)

Here's a personal question/scenario: you administer epi to an anaphylaxis case who could not tell you she/he has cardiac contraindications to epi. Now you are looking at an accelerating and increasingly irregular pulse (and the irregularity of which your automated monitor probably can't interpret).

Ok, now what? Are you balancing anaphylaxis tx against arrhythmia tx?


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## silver (Nov 21, 2012)

Veneficus said:


> I read the study.
> 
> It is deeply flawed, based on protocol and not patient presentation is just one problem.
> 
> It will carry no weight in my future clinical decisions or opinions on EMS.




Is it indexed anywhere? I just want to read it, but I don't even know the title...


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## medic417 (Nov 21, 2012)

Veneficus said:


> I read the study.
> 
> It is deeply flawed, based on protocol and not patient presentation is just one problem.
> 
> It will carry no weight in my future clinical decisions or opinions on EMS.



I agree.  As with many so called research papers the definition used is based on a persons already preconceived notions.  

This would be like saying because a Paramedic told a person they do not need an ambulance yet later the person is admitted to the hospital that the Paramedic was wrong.  We all know better than that Most people that are admitted to the hospital need know ambulance. So now if in my perception Paramedics should not be allowed to say no to transport all I have to do to back up my study is say how many patients that the Paramedic said did not need the ambulance ended up hospitalized.  The numbers would seem to indicate I was right in saying Paramedics should not make the decision.  So obviously while I have numbers to back me my study is flawed big time.

Same with the quoted study


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## Jon (Nov 21, 2012)

Veneficus said:


> I read the study.
> 
> It is deeply flawed, based on protocol and not patient presentation is just one problem.
> 
> It will carry no weight in my future clinical decisions or opinions on EMS.



Good point.

Personally, I'll aggressively give Epi to younger individuals, when it's appropriate.


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## OfficerEvenEMT (Nov 21, 2012)

They seem to say that Epi should be used immediately when there is a confirmed anaphylaxic issue, but that it is not. Ideas why?


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## Veneficus (Nov 21, 2012)

OfficerEvenEMT said:


> They seem to say that Epi should be used immediately when there is a confirmed anaphylaxic issue, but that it is not. Ideas why?



Because it is not confirmed in the field.


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## Veneficus (Nov 21, 2012)

mycrofft said:


> Here's a personal question/scenario: you administer epi to an anaphylaxis case who could not tell you she/he has cardiac contraindications to epi. Now you are looking at an accelerating and increasingly irregular pulse (and the irregularity of which your automated monitor probably can't interpret).
> 
> Ok, now what? Are you balancing anaphylaxis tx against arrhythmia tx?



All of critical care is a balance of competing treatments and interactions.

The simple answer is: Yes.

But there are smarter ways of doing it. Rather than a 1 time SQ or preferably IM bolus, you could use a drip. 

If somebody is in extremis, then by all means, fire away. But...

"Don't use a cannon to kill a mosquito."


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## shfd739 (Nov 21, 2012)

Jon said:


> Good point.
> 
> Personally, I'll aggressively give Epi to younger individuals, when it's appropriate.



Why just younger people? 

I've used Epi IV on severe anaphylaxis. It was needed and my medical director happened to be the recieving ER doc each time thankfully. I got a strange look then he agreed with the use. I knew it was going out on a limb and out of protocol but I was able to justify the use.


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## mycrofft (Nov 21, 2012)

mycrofft said:


> Here's a personal question/scenario: you administer epi to an anaphylaxis case who could not tell you she/he has cardiac contraindications to epi. Now you are looking at an accelerating and increasingly irregular pulse (and the irregularity of which your automated monitor probably can't interpret).
> 
> Ok, now what? Are you balancing anaphylaxis tx against arrhythmia tx?



What I was looking at was more like this: pt is in anaphylaxis; epi given sq; heart rate becomes irregular and very rapid, BP initially rises then may level off or actually fall. Pt c/o chest pain then passes out. Are you going to give a counter-agent and benadryl, try to ride it out, or ??    Wouldn't a counteragent reverse impact on s/s anaphylaxis?

I hate to start trying to titrate TWO drugs with interactions.


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## Aidey (Nov 21, 2012)

shfd739 said:


> Why just younger people?



Because epi is really hard on the heart. If a patient has pre-existing heart disease they can develop some nasty side effects. Younger people with healthy hearts tend to tolerate it much better than older people.


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## Jon (Nov 22, 2012)

Aidey said:


> Because epi is really hard on the heart. If a patient has pre-existing heart disease they can develop some nasty side effects. Younger people with healthy hearts tend to tolerate it much better than older people.



Exactly. If someone were to have a cardiac history, or be older... I'm going to use caution, and I may start off with Benadryl and Albutorol if at all possible. I'll still go with epi, but I'm not going to be as quick to give it.

Whereas a pediatric patient or adult, I'm going to aggressively give Epi if it's indicated. It is remarkable how quick the patient can better.


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## OfficerEvenEMT (Nov 22, 2012)

Jon said:


> Exactly. If someone were to have a cardiac history, or be older... I'm going to use caution, and I may start off with Benadryl and Albutorol if at all possible. I'll still go with epi, but I'm not going to be as quick to give it.
> 
> Whereas a pediatric patient or adult, I'm going to aggressively give Epi if it's indicated. It is remarkable how quick the patient can better.



What do you do when the protocols specifically say epi first?


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## Jon (Nov 22, 2012)

OfficerEvenEMT said:


> What do you do when the protocols specifically say epi first?



Hence the base of this study.

PA's protocols, for example, do specify immediate Epi in severe allergic reactions, but also talk about using caution w/ giving Epi to patients over 50.
So I have 2 options - First is to call it "moderate" vs. severe, and 2nd is to "use caution".

There's no one right answer, In the end it comes down to being a clinician vs. blindly following the cookbook.


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## Medic Tim (Nov 22, 2012)

OfficerEvenEMT said:


> What do you do when the protocols specifically say epi first?



Treat the pt to the best of your knowledge and ability. Protocols should not take the place of sound clinical judgment/ common sense*. In the systems I have worked in/currently work in, as long as we can back up why/what we did, there is never an issue (For something major... if time permits we may call OLMC). We are encouraged to treat the pt and not force them into the closest protocol we have, then follow it blindly. (clinician vs technician)

*that is assuming the provider(s) have any 

 I have never worked or have experience with an all basic system but I would guess deviation from protocols is frowned upon due to limited scope and minimal education (not a slam against basics). I am sure there are ALS services as well where the medical director expects you to not have a brain and follow the cookbook.


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## VFlutter (Nov 22, 2012)

Medic Tim said:


> *that is assuming the provider(s) have any



That is a pretty big assumption to make and you know what they say about assuming....


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## shfd739 (Nov 22, 2012)

Jon said:


> Hence the base of this study.
> 
> PA's protocols, for example, do specify immediate Epi in severe allergic reactions, but also talk about using caution w/ giving Epi to patients over 50.
> So I have 2 options - First is to call it "moderate" vs. severe, and 2nd is to "use caution".
> ...



Same as our protocols. 

Even if it is severe and they are older i can use smaller doses instead of not using at all. 

Case by case based on the patient and their history for me.


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## OfficerEvenEMT (Nov 22, 2012)

Medic Tim said:


> Treat the pt to the best of your knowledge and ability. Protocols should not take the place of sound clinical judgment/ common sense*. In the systems I have worked in/currently work in, as long as we can back up why/what we did, there is never an issue (For something major... if time permits we may call OLMC). We are encouraged to treat the pt and not force them into the closest protocol we have, then follow it blindly. (clinician vs technician)
> 
> *that is assuming the provider(s) have any
> 
> I have never worked or have experience with an all basic system but I would guess deviation from protocols is frowned upon due to limited scope and minimal education (not a slam against basics). I am sure there are ALS services as well where the medical director expects you to not have a brain and follow the cookbook.



Aren't deviations from protocols what causes successful malpractice lawsuits?


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## Veneficus (Nov 22, 2012)

OfficerEvenEMT said:


> Aren't deviations from protocols what causes successful malpractice lawsuits?



no.


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## usalsfyre (Nov 22, 2012)

OfficerEvenEMT said:


> Aren't deviations from protocols what causes successful malpractice lawsuits?


Nope. Blindly following the wrong or inappropriate protocol will cause you problems just as surely.


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## STXmedic (Nov 22, 2012)

OfficerEvenEMT said:


> Aren't deviations from protocols what causes successful malpractice lawsuits?



Attempting to hide deviating (intentionally or unintentionally) from protocols certainly will. Not so much if its documented/reported appropriately.


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## Medic Tim (Nov 22, 2012)

OfficerEvenEMT said:


> Aren't deviations from protocols what causes successful malpractice lawsuits?



Not at all......as long as you are doing it for the right reasons, within scope and report it.


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## KellyBracket (Nov 22, 2012)

Great topic! It's a good area to review, and paramedics should know this stuff cold.

That said, there's a lot of misinformation, myth, or outdated stuff out there. I've reviewed this topic a few times in  "*Anaphylaxis Knowledge Among Paramedics*", " *New Guidelines for Anaphylaxis *", and " *Anaphylactic reactions - 5 things.* ". 

Let me just put out a few "controversial" statements that are actually part of the conventional thinking, based in the research, and are in the guidelines (read my reviews for links to sources).

*Epi is the only medicine for anaphylaxis.* 
There is no evidence that steroids or antihistamines do anything for anaphylaxis, or even that do they do anything to prevent "biphasic" anaphylaxis. One study protocol used only epi for anaphylaxis (and O2 and NS), and patients did fine. 

*Anaphylaxis is more than hypotension and stridor.*
In fact, GI symptoms are a very concerning element of anaphylaxis, and are part of the standard definition of anaphylaxis. Urticaria and vomiting, after exposure to a likely allergen, is anaphylaxis, according to the experts.

*Anaphylaxis causes MIs*
While there are case reports of people having problems with epi, usually after receiving whopping IV doses (e.g 100 µg), there are also plenty of reports of people having MIs due to untreated anaphylaxis - it's called *Kounis syndrome*. 

*There are no absolute contraindications to epi*
Is someone just has some itchy skin, that's not anaphylaxis. But true anaphylaxis needs true treatment, and the expert EPs and allergists agree (pdf download) - there is no absolute contraindication to epi.


If you think I'm being controversial, just check out the sources, and see what you think!


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## OfficerEvenEMT (Nov 22, 2012)

PoeticInjustice said:


> Attempting to hide deviating (intentionally or unintentionally) from protocols certainly will. Not so much if its documented/reported appropriately.



That doesn't make much sense, sorry. If you tell the PT they need a ride in a UFO and this will stop them from bleeding you can't successfully defend a malpractice suit even if you document it in your PCR.

Documentation in PCR ≠ immunity from a lawsuit

Following protocols = good defense


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## ffemt8978 (Nov 22, 2012)

officerevenemt said:


> following correct protocols = good defense



ftfy


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## Aidey (Nov 22, 2012)

OfficerEvenEMT said:


> That doesn't make much sense, sorry. If you tell the PT they need a ride in a UFO and this will stop them from bleeding you can't successfully defend a malpractice suit even if you document it in your PCR.
> 
> Documentation in PCR ≠ immunity from a lawsuit
> 
> Following protocols = good defense



That isn't malpractice. 

What Poetic is saying is that if you deviate from protocol for a good reason and document it thoroughly you are in a much better position than if you deviate from protocol and don't document it or try and hide it. There are plenty of legitimate reasons to deviate from protocol, such as the patient is allergic to the medication indicated for their condition, or the little old lady who fell down is super kyphotic and you can't get her in a c-collar. 

And following protocols do not save you from malpractice lawsuits. Following protocols will possibly save you from your company and medical director, but they will not save you from anyone else.


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## OfficerEvenEMT (Nov 22, 2012)

Aidey said:


> That isn't malpractice.
> 
> What Poetic is saying is that if you deviate from protocol for a good reason and document it thoroughly you are in a much better position than if you deviate from protocol and don't document it or try and hide it. There are plenty of legitimate reasons to deviate from protocol, such as the patient is allergic to the medication indicated for their condition, or the little old lady who fell down is super kyphotic and you can't get her in a c-collar.
> 
> And following protocols do not save you from malpractice lawsuits. Following protocols will possibly save you from your company and medical director, but they will not save you from anyone else.



Attorneys for the plaintiff will not see if that way and often convince juries of just that. Juries hear "did not follow protocol" and not "sound clinical judgement". In this case, however, the study seems to say that avoiding epi when it is indicated is poor clinical judgement.


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## VFlutter (Nov 22, 2012)

OfficerEvenEMT said:


> Following protocols = good defense



Just FYI...that BS excuse may keep you out of trouble but it really doesn't fly in the medical community. If a medic ever gave me the "following protocols" line in regards to rationale for patent care then I would immediately lose all respect for that individual as a compotent healthcare practioner. From that point on they are noting more than a cookbook technician and about as valuable as a trained monkey, but less cute. 


/End rant


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## Aidey (Nov 22, 2012)

OfficerEvenEMT said:


> Attorneys for the plaintiff will not see if that way and often convince juries of just that. Juries hear "did not follow protocol" and not "sound clinical judgement". In this case, however, the study seems to say that avoiding epi when it is indicated is poor clinical judgement.



Wanna bet? Yes, those are things that lawyers like to throw out there, but following protocol WILL NOT SAVE YOU. Period. There are several hundred different sets of protocols in this country. For that argument to work you better have done something that is outside any of them and was so stupid that it is easy to prove you should have known better. 

Here is a great example. High dose nitro is not in my protocols for CHF/Pulmonary edema. It is also well known to be one of two effective pre-hospital treatments for those conditions. If I had a patient in extremis who I gave high dose nitro to, and who later died, it would be almost impossible for me to lose a malpractice lawsuit. Even though I was outside of my local protocols I was well within the accepted standard of care.


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## OfficerEvenEMT (Nov 22, 2012)

ChaseZ33 said:


> Just FYI...that BS excuse may keep you out of trouble but it really doesn't fly in the medical community. If a medic ever gave me the "following protocols" line in regards to rationale for patent care then I would immediately lose all respect for that individual as a compotent healthcare practioner. From that point on they are noting more than a cookbook technician and about as valuable as a trained monkey, but less cute.
> 
> 
> /End rant



I disagree and I also do not want to lose my EMT card for failing to follow protocols.


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## VFlutter (Nov 22, 2012)

OfficerEvenEMT said:


> I disagree and I also do not want to lose my EMT card for failing to follow protocols.



Disagree with which part? You would have to do something blatantly idiotic to lose it.


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## Aidey (Nov 22, 2012)

I know if exactly 3 paramedics out of the few hundred in my county who have had their cert revoked at the state level in the last few years. One assaulted a patient, the other 2 were diverting narcotics. I have also heard of some _*phenomenally *_dumb protocol deviations. All of those were dealt with in house, by the agency employing the paramedic.


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## VFlutter (Nov 22, 2012)

Aidey said:


> I know if exactly 3 paramedics out of the few hundred in my county who have had their cert revoked at the state level in the last few years. One assaulted a patient, the other 2 were diverting narcotics. I have also heard of some _*phenomenally *_dumb protocol deviations. All of those were dealt with in house, by the agency employing the paramedic.



And those are paramedics....what would a Basic have to do? I don't see it happening for anything except stealing narcs, assault, or something stupid resulting in serious harm.


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## OfficerEvenEMT (Nov 22, 2012)

ChaseZ33 said:


> Disagree with which part? You would have to do something blatantly idiotic to lose it.



Like disregarding protocols. EMTs and paramedics do not independently practice medicine- they only practice under a physician's license and prescribed protocols. Have you asked what the physician would think by disregarding his orders?


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## OfficerEvenEMT (Nov 22, 2012)

ChaseZ33 said:


> And those are paramedics....what would a Basic have to do? I don't see it happening for anything except stealing narcs, assault, or something stupid resulting in serious harm.



Under this logic a Basic would be fine for operating outside their scope (starting IVs, pushing meds, etc) as long as they have good justification and documented it, despite not having protocols allowing it.


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## Shishkabob (Nov 22, 2012)

When I first read the study I knew off the bat it was flawed and the writers had little to no clue what they were actually talking about EMS wise.


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## Wheel (Nov 22, 2012)

OfficerEvenEMT said:


> Under this logic a Basic would be fine for operating outside their scope (starting IVs, pushing meds, etc) as long as they have good justification and documented it, despite not having protocols allowing it.



Operating outside of your scope and training is very different from operating within scope, somewhat out of protocol.


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## Tigger (Nov 22, 2012)

Wheel said:


> Operating outside of your scope and training is very different from operating within scope, somewhat out of protocol.



Beat me too it. For most basics (not me right ironically) starting an IV is not in their scope of practice period. Therefore it cannot be in their protocols. Meanwhile, there are many protocols that do not include all the interventions found in the scope of practice for a provider. Providing one of these interventions if it is not in your protocols is not bad medicine, nor is it negligent as it has already been accepted and proven as effective.


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## reaper (Nov 22, 2012)

OfficerEvenEMT said:


> Under this logic a Basic would be fine for operating outside their scope (starting IVs, pushing meds, etc) as long as they have good justification and documented it, despite not having protocols allowing it.



No, then you are operating outside your scope of practice. Most good medical directors have a statement in the begining of their protocol books. It will state that they are "guidelines to help your decision base, but do not override sound clinical judgement". That's all protocols are, guidelines. Not a treatment map that has to be followed by the letter.

No offense, but you sound like you are spewing the garbage talk in EMT classes. They scare people into  following cookbooks, so they won't have to teach clinical decision making. That is geared towards the least common denominators (the stupid folks). 

Instead of arguing every statement given, learn from them!

My protocols state that I may give epi to any pt I deem needs it off my clinical judgement. This happens when you have Md that understands the needs in the field.

EMS is different every where. Some systems trust their providers and some don't . Learn all you can and use your knowledge to make sound choices for your pts. But, never step outside your scope. That will go bad quickly.


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## OfficerEvenEMT (Nov 22, 2012)

reaper said:


> No, then you are operating outside your scope of practice. Most good medical directors have a statement in the begining of their protocol books. It will state that they are "guidelines to help your decision base, but do not override sound clinical judgement". That's all protocols are, guidelines. Not a treatment map that has to be followed by the letter.
> 
> No offense, but you sound like you are spewing the garbage talk in EMT classes. They scare people into  following cookbooks, so they won't have to teach clinical decision making. That is geared towards the least common denominators (the stupid folks).
> 
> ...




I'm only thinking from a legal POV (which is my training and job). I only do that is lawful and what our lawyers say it OK. When our officers and EMTs diverge from those rules then they are suddenly unemployed.


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## NYMedic828 (Nov 22, 2012)

OfficerEvenEMT said:


> Have you asked what the physician would think by disregarding his orders?



Yep. Just about every time I call medical control...


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## VFlutter (Nov 22, 2012)

OfficerEvenEMT said:


> I'm only thinking from a legal POV (which is my training and job). I only do that is lawful and what our lawyers say it OK. When our officers and EMTs diverge from those rules then they are suddenly unemployed.



It sounds like you are a LEO who is also an EMT working for a police department? Since when are protocols a law? Do your lawyers have an active role in developing them? I would suggest you look over your protocol book again, like other have stated there is usually a statement about clinical judgment and being guidelines not absolutes. 


If only every patient was a cookie cutter textbook example of a single disease process then we could all happily follow protocols and never use dat der "critical thinking" crap dey always be takin bout.


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## reaper (Nov 22, 2012)

OfficerEvenEMT said:


> I'm only thinking from a legal POV (which is my training and job). I only do that is lawful and what our lawyers say it OK. When our officers and EMTs diverge from those rules then they are suddenly unemployed.



So what here that anyone has said is illegal?


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## OfficerEvenEMT (Nov 23, 2012)

NYMedic828 said:


> Yep. Just about every time I call medical control...



You are either asking for permission or receiving his commands. Remember, you do not practice medicine independently.


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## OfficerEvenEMT (Nov 23, 2012)

ChaseZ33 said:


> It sounds like you are a LEO who is also an EMT working for a police department? Since when are protocols a law? Do your lawyers have an active role in developing them? I would suggest you look over your protocol book again, like other have stated there is usually a statement about clinical judgment and being guidelines not absolutes.
> 
> 
> If only every patient was a cookie cutter textbook example of a single disease process then we could all happily follow protocols and never use dat der "critical thinking" crap dey always be takin bout.



This is true about my job. We do EMS response in addition to LE. Not only are our protocols established by our physician medical director but they are legal standing orders from our chief.


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## NYMedic828 (Nov 23, 2012)

OfficerEvenEMT said:


> You are either asking for permission or receiving his commands. Remember, you do not practice medicine independently.



Correct. Because I am asking permission to administer a medication that is not in protocol for the specific purpose I would like to use it for. For example if I want to administer 5mg of valium to relieve severe back spasm. Has no grounds in the protocol book anywhere whatsoever but I can still do it. 

At the same time I can also tell that doctor "no" i will not do something he asks of me in the event I feel it would have a negative outcome for the patient.

Anyone in a hospital who administers care and isn't a doctor, works under a doctor. A nurse can administer any medication the doctor prescribes same as a paramedic (assuming it is available.) But a doctor cannot ask a PCA to administer it because it is not within their scope.




OfficerEvenEMT said:


> This is true about my job. We do EMS response in addition to LE. Not only are our protocols established by our physician medical director but they are legal standing orders from our chief.



I hate to tell a police officer what is and is not law...

But I will tell you that your agency is in fact flawed or your teaching and understanding what protocols are is flawed. Your chief can implement whatever standing orders he wants but if you perform it, and you cause harm to the patient, you are at fault. Your protocols won't save you if you commit any form of non/mal/misfeasance or tort.

If your protocol says to administer an epi pen for an asthmatic reaction, does that mean every asthmatic reaction MUST get an epi pen? No absolutely not. But at the same time if you administer that epi pen and it causes harm, you are at fault if you cannot justify your actions to the T. Your protocol is a guideline. Under no circumstances are protocols to be considered law. Ever.


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## RocketMedic (Nov 23, 2012)

KellyBracket said:


> Great topic! It's a good area to review, and paramedics should know this stuff cold.
> 
> That said, there's a lot of misinformation, myth, or outdated stuff out there. I've reviewed this topic a few times in  "*Anaphylaxis Knowledge Among Paramedics*", " *New Guidelines for Anaphylaxis *", and " *Anaphylactic reactions - 5 things.* ".
> 
> ...



I actually managed to piss my FTO off with this- apparently, uticaria/hives/slight stridor 15 minutes post-peanut ingestion on a 13 month old isn't _quite_ enough reason to draw up epi and benadryl instead of repeating an assessment that's already pointed you straight at allergy/anaphylaxis. But no, we need a BP...

Remember good medicine?


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## OfficerEvenEMT (Nov 23, 2012)

NYMedic828 said:


> Correct. Because I am asking permission to administer a medication that is not in protocol for the specific purpose I would like to use it for. For example if I want to administer 5mg of valium to relieve severe back spasm. Has no grounds in the protocol book anywhere whatsoever but I can still do it.



As long as you ask for permission to deviate from the protocols and this is documented then it's probably fine. It's practicing medicine outside of the established protocols that leaves someone unemployed and on the receiving end of a lawsuit.



> At the same time I can also tell that doctor "no" i will not do something he asks of me in the event I feel it would have a negative outcome for the patient.
> 
> Anyone in a hospital who administers care and isn't a doctor, works under a doctor. A nurse can administer any medication the doctor prescribes same as a paramedic (assuming it is available.) But a doctor cannot ask a PCA to administer it because it is not within their scope.


True, and this is a good idea. I have seen PCAs administer meds when it was allowed by hospital protocol.



> I hate to tell a police officer what is and is not law...
> 
> But I will tell you that your agency is in fact flawed or your teaching and understanding what protocols are is flawed. Your chief can implement whatever standing orders he wants but if you perform it, and you cause harm to the patient, you are at fault. Your protocols won't save you if you commit any form of non/mal/misfeasance or tort.



The chief counter signs the SMOs that the physician medical director establishes, with a note saying that these are orders to us. We don't go to jail if we violate them but we run the risk of becoming unemployed and being on the receiving end of a malpractice lawsuit.



> If your protocol says to administer an epi pen for an asthmatic reaction, does that mean every asthmatic reaction MUST get an epi pen? No absolutely not. But at the same time if you administer that epi pen and it causes harm, you are at fault if you cannot justify your actions to the T. Your protocol is a guideline. Under no circumstances are protocols to be considered law. Ever.



The protocols aren't law but adherence to them is a _legal order_ from both the PMD and chief. If the SMOs say for my to administer an EpiPen to someone who has all the signs and symptoms of anaphylaxis then I surely will do that.


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## Milla3P (Nov 23, 2012)

Stepping away from the dead horse and back towards medicine...

Does anybody else have terbutaline in their bag of tricks for elderly/cardiac Hx? Thoughts? I've seen it be pretty effective.


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## DrParasite (Nov 23, 2012)

NYMedic828 said:


> Correct. Because I am asking permission to administer a medication that is not in protocol for the specific purpose I would like to use it for. For example if I want to administer 5mg of valium to relieve severe back spasm. Has no grounds in the protocol book anywhere whatsoever but I can still do it.


And what if he says no?  are you permitted to administer it anyway? you can ask for permission to be creative, but remember, a doctor still needs to approve you deviating from protocol.





NYMedic828 said:


> At the same time I can also tell that doctor "no" i will not do something he asks of me in the event I feel it would have a negative outcome for the patient.


really?  so if the doctor orders you to administer epinephrine, and you decide not to because you think it won't be good for the patient, you can do that?  didn't i see that on an early episode of Rescue 77 10+ years ago?  

What would the reaction be if the doctor filed a complaint with your supervisor over it, would your supervisor back you or the doctor?


NYMedic828 said:


> But I will tell you that your agency is in fact flawed or your teaching and understanding what protocols are is flawed. Your chief can implement whatever standing orders he wants but if you perform it, and you cause harm to the patient, you are at fault. Your protocols won't save you if you commit any form of non/mal/misfeasance or tort.


ummm, yes and no.  while you are at fault, as long as you have written protocol backing your action, the AGENCY should bear the brunt of any lawsuit, not the individual.

Now, if you deviate from protocol WITHOUT permission from medical control, and there is a negative outcome, expect your agency to hang you out to dry, and you to be on the hook for everything that results from it, both civilly and criminally.

By the way, you might keep your cert if you have a justifiable reason to deviate from protocol, without approval of medical control, especially if it's based on current medical practices.  But you might not keep your job with your employer.


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## ffemt8978 (Nov 23, 2012)

We've strayed a bit from the original topic into a debate about following protocols.  Let's get back on topic, and if you want to talk about following protocols please start a new thread.


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## VFlutter (Nov 23, 2012)

DrParasite;442792. said:
			
		

> really?  so if the doctor orders you to administer epinephrine, and you decide not to because you think it won't be good for the patient, you can do that?  didn't i see that on an early episode of Rescue 77 10+ years ago?



Speaking from an RN point of view (I assume it would be the same with a paramedic) you have every right to refuse to perform a procedure or give a medication if you think it will result in patient harm. However, you better be able to back it up with evidence. Already in my short career I have witnessed doctors giving inappropriate orders and then getting angry when nurses refuse to do it. They can complain all they want but the RN still has a license to protect and can be reprimanded even for following a direct order from an MD


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## DrParasite (Nov 23, 2012)

ChaseZ33 said:


> They can complain all they want but the RN still has a license to protect and can be reprimanded even for following a direct order from an MD


Can an RN be reprimanded for refusing to follow a direct order from an MD?  One that she doesn't think should be given, but the doctor has a clinical reason backed by education that he wants to have it done?


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## ffemt8978 (Nov 23, 2012)

Back on topic, please.


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## DrParasite (Nov 23, 2012)

ffemt8978 said:


> Back on topic, please.


With all due respect, I don't believe we are that off topic.  

As I read it, the OP's question was that Paramedics are not giving the proper medications based on the current lines of medicine by the allergy doctors.  The logical explanation (at least in my eyes) is that a paramedic can know that they aren't giving the proper medication, but due to their medical directors protocol, they still have to follow the rules.

Yes, it's a much more general discussion, but it can be very relevant to the topic at hand (if a paramedic knows their is a medication that is better suited, can they go outside of protocol and give it).


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## ffemt8978 (Nov 23, 2012)

When we're discussing the legalities of following protocols, then we've strayed off topic.


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## OfficerEvenEMT (Nov 23, 2012)

Is Epi the quickest acting med to use for anaphylaxis? The original article seemed to say that it's effects were very quick but medications like benadryl take a very long time. I also see that steroids are used. Why? Does it have something to do with the immune system, like the steroids used for antirejection meds?


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## VFlutter (Nov 23, 2012)

DrParasite said:


> Can an RN be reprimanded for refusing to follow a direct order from an MD?  One that she doesn't think should be given, but the doctor has a clinical reason backed by education that he wants to have it done?



If the RN has a legitimate concern then most likely not. For example, lets say a MD orders you to push an IV med that you think is not supposed to be IV or is at too high of a dose for IV admin then you have the right to refuse until it is cleared by pharmacy or another MD. He can sit there and yell all he wants about his previous experience or current recommendations that are not yet published but it really won't get him anywhere if I do not feel comfortable pushing it. Or the typical nurse response is "you push it yourself then". Lets say I pushed that med, under direct MD supervision/order, and the patient dies. I could still lose my license.


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## mycrofft (Nov 23, 2012)

Epi is quick in and quick out, unless you give a sustained release version.  
Benadryl is not given until acute s/s of anaphylaxis are controlled, per NIH; however, also per this website, injectable diphenhydramine (Benadryl) is "fast acting".
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=1029


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## Veneficus (Nov 23, 2012)

ChaseZ33 said:


> Or the typical nurse response is "you push it yourself then"



Could you teach other nurses this line?

I have no problem pushing the meds myself. In fact I prefer it.


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## VFlutter (Nov 23, 2012)

Veneficus said:


> Could you teach other nurses this line?
> 
> I have no problem pushing the meds myself. In fact I prefer it.



In regards to all meds or just emergent situations? 

During clinical one RN refused to give a 100mg IV lasix bolus to a patient who's Bp was soft so the doctor said he would do it himself. He walked in and literally *slammed * the bolus in under 30 seconds and walked right out. We were all speechless. The patient was fine. The doctor was not really mad about it more just annoyed. I totally believe he knew what he was doing however it went against everything I was taught and used to so I would have still been uncomfortable doing it myself.


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## Veneficus (Nov 23, 2012)

ChaseZ33 said:


> In regards to all meds or just emergent situations?



All meds. Particularl IV antibiotics.



ChaseZ33 said:


> During clinical one RN refused to give a 100mg IV lasix bolus to a patient who's Bp was soft so the doctor said he would do it himself. He walked in and literally *slammed * the bolus in under 30 seconds and walked right out. We were all speechless. The patient was fine. The doctor was not really mad about it more just annoyed. I totally believe he knew what he was doing however it went against everything I was taught and used to so I would have still been uncomfortable doing it myself.



I have encountered this recently. I am of the opinion that lack of understanding of both volume of distribution and potential or experienced pathophysiology of various "fast push" medications is not well understood by nurses and leads to often unreasonable dogma being accepted as fact.

The best way I can describe it is that experience does not equal understanding.


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## systemet (Nov 23, 2012)

OfficerEvenEMT said:


> Is Epi the quickest acting med to use for anaphylaxis?



Yes. Of the commonly-used medications it has the most rapid onset of effect.  It's even quicker given IV, as you would imagine.  This carries additional risks and is only usually used in extremis.  



> The original article seemed to say that it's effects were very quick but medications like benadryl take a very long time. I also see that steroids are used. Why? Does it have something to do with the immune system, like the steroids used for antirejection meds?



Yes.  Anaphylaxis is an immune system response to a previously sensitised allergen.  If you suppress the immune system response, you may reduce the severity of the anaphylactic episode.  However, steroids take several hours to peak effect.  So they're unlikely to be beneficial during the prehospital phase, but there's a certain wisdom that if you're already giving a bunch of adjunctive meds like benadry, maybe getting the steroids in a half hour or an hour earlier might be beneficial.  Anaphylactic reactions can often be biphasic, and a dose of steroids may mitigate a secondary response.

I haven't read the article, but would be interested in seeing how they defined anaphylaxis.  I'm skeptical of the numbers, but anaphylaxis can occur with a wide range of presentations, and without characteristic uriticaria, pruritis or angioedema.


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## NYMedic828 (Nov 23, 2012)

KellyBracket said:


> Great topic! It's a good area to review, and paramedics should know this stuff cold.
> 
> That said, there's a lot of misinformation, myth, or outdated stuff out there. I've reviewed this topic a few times in  "*Anaphylaxis Knowledge Among Paramedics*", " *New Guidelines for Anaphylaxis *", and " *Anaphylactic reactions - 5 things.* ".
> 
> ...



Quick question for you doc,

I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.

In my relatively short time as a medic, it seems to be common practice to use the deltoids for any IM injection we give. In my program they usually teach the deltoids to be the most useful site for any medication we carry IM up to 3ccs I believe. (on adults)

What is the actual medical reason that the thigh is superior? Is it superior for all IM medications? I have only given epi a handful of times and every time it has been in the delt. (granted it has worked every time)


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## Medic Tim (Nov 23, 2012)

NYMedic828 said:


> Quick question for you doc,
> 
> I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.
> 
> ...



 I once had a partner (lower license level) report me for giving epi in the AL thigh because they said it was dangerous lol.. I guess they were taught to give all IMs in the delt.


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## KellyBracket (Nov 23, 2012)

Consolidated responses...


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## KellyBracket (Nov 23, 2012)

NYMedic828 said:


> Quick question for you doc,
> 
> I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.
> 
> ...



I just want to be clear - it's not my own crackpot opinion! This reccomendation comes from, basically, every reference document and (current) textbook out there. 

This is mostly based on two studies, one in kids & the other in adults, that showed that IM in the thigh was the only route that demonstrated a real bump in epi levels. IM in the deltoid, by contrast, was close to placebo! I reproduced the graphs in reviews *here* and *here*. 

As for whether it is superior for all medications, I can't say. You certainly don't want to give heparin or vitamin K IM. but that's for different reasons!


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## NYMedic828 (Nov 24, 2012)

KellyBracket said:


> I just want to be clear - it's not my own crackpot opinion! This reccomendation comes from, basically, every reference document and (current) textbook out there.
> 
> This is mostly based on two studies, one in kids & the other in adults, that showed that IM in the thigh was the only route that demonstrated a real bump in epi levels. IM in the deltoid, by contrast, was close to placebo! I reproduced the graphs in reviews *here* and *here*.
> 
> As for whether it is superior for all medications, I can't say. You certainly don't want to give heparin or vitamin K IM. but that's for different reasons!



Haha, definitely not assuming its your own opinion. I was just curious because my program advocated the deltoid. My assumption is that it is due to 1 part laziness and 1 part misinformation. The delt is definitely easier to access in most patients and If the instructor doesn't know it, odds are the students aren't going to learn it.

As far as it having a placebo effect in the deltoids i find that a little hard to believe. I have seen it work perfectly fine when given in the deltoids. I would be hard pressed to believe that patients are subconsciously increasing their HR to 150+ bpm. It just doesn't seem possible especially if they don't know what you gave them.




While we are on the topic of paramedics and anaphylaxis, could you take a moment to break down why we don't give atrovent in conjunction with albuterol for treating broncho-constriction in anaphylaxis?

At least here in NYC we don't. We give albuterol only. I have been told in the past we do not give it because anaphyalxis is not a cholinergic mediated process but at the same time wouldn't decreasing parasympathetic tone indirectly increase sympathetic tone aiding in bronchodilation with albuterol and epi?


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## RocketMedic (Nov 24, 2012)

Quit thinking, you! Kool-Aid!


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## mycrofft (Nov 24, 2012)

I've seen epi given each way and it worked. However, the infarct caused by the epi is better tolerated in the thigh than the deltoid, especially in little old people.


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## Veneficus (Nov 24, 2012)

KellyBracket said:


> I just want to be clear - it's not my own crackpot opinion!



I have a high appreciation for crackpot opinions. 

Because those crackpots often have something remarkably genius to say.


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## KellyBracket (Nov 24, 2012)

NYMedic828 said:


> Haha, definitely not assuming its your own opinion. I was just curious because my program advocated the deltoid. My assumption is that it is due to 1 part laziness and 1 part misinformation. The delt is definitely easier to access in most patients and If the instructor doesn't know it, odds are the students aren't going to learn it.
> 
> As far as it having a placebo effect in the deltoids i find that a little hard to believe. I have seen it work perfectly fine when given in the deltoids. I would be hard pressed to believe that patients are subconsciously increasing their HR to 150+ bpm. It just doesn't seem possible especially if they don't know what you gave them.
> 
> ...



The studies showed placebo-identical _blood levels_. It's difficult to compare the _clinical_ effectiveness in actual anaphylaxis, given the rarity, and urgency, of the situation.

As for ipratropium, I haven't read anything on the topic, positive or negative. (Okay, one very rare, negative thing!)I would imagine that, since albuterol (like Benadryl, steroids, etc) is adjunctive treatment, it just doesn't matter. Anaphylaxis is a systemic disorder, and you need more than the local action of inhaled agents.


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