# Off duty question



## Caspar (Sep 2, 2013)

This question came up today during lunch. An EMT is off duty and notices someone in clear anaphylaxis without an epi-pen. If someone else has an epi-pen, can you use it on the patient with anaphylaxis? I know that when on duty, you can call medical control to administer the epinephrine, but if you're off duty, can you give it or just call 911?


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## teedubbyaw (Sep 2, 2013)

Is the person conscious?


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## usalsfyre (Sep 2, 2013)

For absolutely clear cut anaphylaxis giving it while conveniently forgetting to identify yourself as an EMS provider is your best bet.


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## J B (Sep 2, 2013)

I think it depends on what state you're in.  I'm pretty sure that in MA you're covered under good samaritan laws.

And it seems wise to not give out your name or identify yourself as a medical professional.


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## xrsm002 (Sep 2, 2013)

It depends what state your in. If it is in fact they person's epi pen and you gave them it I'm pretty sure sure you would be covered and pretty sure most jury's would side with you.


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## Medic Tim (Sep 2, 2013)

usalsfyre said:


> For absolutely clear cut anaphylaxis giving it while conveniently forgetting to identify yourself as an EMS provider is your best bet.



This ^^^


as a layperson you can do this with no questions being asked.

If you identify yourself as an EMT or Medic you risk being reported and getting into trouble.

that said laws vary from state to state.


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## mycrofft (Sep 2, 2013)

Epipen is prescription. Answer is NO since dose may be wrong. Also illegal.


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## unleashedfury (Sep 2, 2013)

mycrofft said:


> Epipen is prescription. Answer is NO since dose may be wrong. Also illegal.



Its illegal to use another persons Physician prescribed medications. As horrid as that sounds. it opens up liability 

Notify 911 and allow the on duty crew to do what they need to do. In the meantime act in the same way a layperson would basic first aid.


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## usalsfyre (Sep 2, 2013)

mycrofft said:


> Epipen is prescription. Answer is NO since dose may be wrong. Also illegal.



They come in two doses. The Jr won't be enough for an adult. The Adult might be too much for a kid but it'll probably be ok. It's not rocket surgery.

As for the legality...this is one of the few cases where my personal ethics win out. Those of you who know me know that I'm not by any means one to play the off duty wacker. But there is an incredibly real chance this patient will die without rapid intervention. Deliver the treatment, then fade out...


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## Medic Tim (Sep 2, 2013)

usalsfyre said:


> They come in two doses. The Jr won't be enough for an adult. The Adult might be too much for a kid but it'll probably be ok. It's not rocket surgery.
> 
> As for the legality...this is one of the few cases where my personal ethics win out. Those of you who know me know that I'm not by any means one to play the off duty wacker. But there is an incredibly real chance this patient will die without rapid intervention. Deliver the treatment, then fade out...



Yep. I may or may not have used a couple of my epi pens on a stranger while on vacation in the Dominican, they had a BAD reaction to shellfish and didn't have their dpi pen on them.


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## NomadicMedic (Sep 2, 2013)

Funny, my sister used her Rx Epi on a stranger while on a trip in Asia. It was smart thinking and she never thought twice about it. Would I do it here? In a second.


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## Handsome Robb (Sep 2, 2013)

Poke em, don't ID yourself (name or "I'm An EmT lOlZ!!!!") and when the crew shows up let them no an Epi pen was administered and go on your merry way.

I agree with the other guys on here, this is one of the very few situations where I would intervene.


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## Tigger (Sep 2, 2013)

Do people out there really have to call medical control to give an epi pen? That just seems a bit absurd to me.

Same with aspirin for that matter.


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## Jim37F (Sep 2, 2013)

Tigger said:


> Do people out there really have to call medical control to give an epi pen? That just seems a bit absurd to me.
> 
> Same with aspirin for that matter.



Even in LA County I can "Assist patients with the administration of physician prescribed self-administered emergency medications if indications are met and no contraindications are present" with out having to call first. Granted it becomes an automatic ALS transport though.


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## Rialaigh (Sep 3, 2013)

usalsfyre said:


> They come in two doses. The Jr won't be enough for an adult. The Adult might be too much for a kid but it'll probably be ok. It's not rocket surgery.
> 
> As for the legality...this is one of the few cases where my *personal ethics win out*. Those of you who know me know that I'm not by any means one to play the off duty wacker. But there is an incredibly real chance this patient will die without rapid intervention. Deliver the treatment, then fade out...




Words out of my mouth


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## Christopher (Sep 3, 2013)

Yanks said:


> This question came up today during lunch. An EMT is off duty and notices someone in clear anaphylaxis without an epi-pen. If someone else has an epi-pen, can you use it on the patient with anaphylaxis? I know that when on duty, you can call medical control to administer the epinephrine, but if you're off duty, can you give it or just call 911?



In NC you can, but obviously this varies from State to State.


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## Christopher (Sep 3, 2013)

Christopher said:


> In NC you can, but obviously this varies from State to State.



I'll revise my prior statement: 10A NCAC 13P .0509 was revised to restrict its usage by credentialed providers in 2009, which I missed. Previously it was understood that EMS providers could do this as well. 

I put epi-pens up there with Aspirin, Albuterol, etc. It is common knowledge to use these in their given situations and thus would not be out of line to "assist with administration" (if you'd like to get weasely about it).

Also, it would be perfectly fine to administer the epi-pen after talking with dispatchers as EMD will direct you to administer them if available.


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## mycrofft (Sep 3, 2013)

There's a three-way breaking point...is it legal, will it work, is it needed? 
I don't include "Am I willing to take the consequences" because any fool can say "yes". And you need to already have that question settled.


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## medservguru88 (Sep 3, 2013)

epi pens have 2 doses 0.3 for adult and 0.15 foe pedi. In the event you come across this do not identify yourself as an emt and apply epi. this will cover you under "good samaritan laws" in your area.


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## Christopher (Sep 3, 2013)

mycrofft said:


> There's a three-way breaking point...is it legal, will it work, is it needed?
> I don't include "Am I willing to take the consequences" because any fool can say "yes". And you need to already have that question settled.



All I ask myself when off duty is if the moral duty is stronger than my legal duty.

To turn this question around:

If I learned a trained individual sat around and _did nothing_, for say a family member of mine, simply because they were off duty when they knew (a) what to do, (b) how to do it, and (c) had the means to do so, I would be inclined to sue them.

In some States I could have a chance at proving duty, in others I would have no hope. You may unwittingly have a duty in some States if the individual is a minor and you are found to be at least partially "responsible" for them (special relationship is the term I believe, and it applies to other areas).

Paging Wes J.D., paging Wes J.D. ...


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## Wes (Sep 3, 2013)

While I do enjoy educating folks on medical-legal issues, I really try to stay out of these discussions for a couple of reasons.  

First, laws regarding tort liability (including duty to act and negligence), Good Samaritan statutes, and regulations on EMS practice are INCREDIBLY variable from state to state.  The overwhelming majority of laws relating to EMS are enacted and interpreted at the state level.  As I'm a Texas attorney, any opinions that I might have, which are NOT legal advice, would be based solely on my understandings of Texas law, which probably wouldn't apply unless the case occured in Texas.

Second, each situation has a different set of facts.  As the old saying goes, bad facts make for bad law.  I really hesitate to get into a fact-specific situation as the specific facts of a case, even hypothetical, may lead to a legal conclusion that might not be generally applicable.

Finally, while I do enjoy the educational opportunities and the banter, I often find myself in a situation where I'm fighting a non-attorney whose arguments and understandings are based on dogma, personal biases, urban legends, war stories from their instructor, and a lack of understanding of law and legal reasoning turn the discussion into the legal equivalent of arguing with a brick wall.  Such is the nature of some EMS forums online.  Further, it pains me when so many people want to protect their professional bailiwicks such as EMS or nursing, yet feel perfectly comfortable giving a legal opinion.

I apologize for disappointing, Christopher, but I decline to participate in giving an opinion on the facts presented in what may or may not be a hypothetical discussion. I do appreciate the opportunity to share why I participate so rarely in EMS legal discussions online, though.


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## DesertMedic66 (Sep 3, 2013)

Don't identify yourself as an EMT or Medic. Administer the Epi and then blend into the back ground and leave. At least that is what I would have done.


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## Christopher (Sep 3, 2013)

Wes said:


> I apologize for disappointing, Christopher, but I decline to participate in giving an opinion on the facts presented in what may or may not be a hypothetical discussion. I do appreciate the opportunity to share why I participate so rarely in EMS legal discussions online, though.



Your signature is clear, so no disappointment here. Your participation certainly illustrates how convoluted this topic actually is!

_(and I sort of expected that reply)_


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## mycrofft (Sep 3, 2013)

medservguru88 said:


> epi pens have 2 doses 0.3 for adult and 0.15 foe pedi. In the event you come across this do not identify yourself as an emt and apply epi. this will cover you under "good samaritan laws" in your area.



Good stand-up sort of answer. :rofl:


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## mycrofft (Sep 3, 2013)

Assume anyone can try to sue you for anything. Unless the plaintiff's attorney or the court act, it can go through since we all deserve our turn as a plaintiff. Good acts or bad. THat's why even if you seem to be OK behiond "Good Sam", you need a lawyer.

I figure telling people how I'd be willing to break the law, or how often I'd broken the law, to act like this is like bragging how many guns you have at home. No one's business but mine.


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## mycrofft (Sep 3, 2013)

Christopher said:


> All I ask myself when off duty is if the moral duty is stronger than my legal duty.
> 
> .



Maybe that will help you sleep at night, but first comes "Will it work?" and "Is it needed?".

People forget that laws and protocols are there for a reason. They may sometimes prove to be outdated or wrongheaded reasons, but there is the germ of an idea there usually sparked by an occasion where something---went---sideways.

AND I QUOTE the EpiPen's manufacturer:

 Important Safety Information

EpiPen® (epinephrine) Auto-Injectors contain a single dose of epinephrine, which you inject into your outer thigh. DO NOT INJECT INTO YOUR VEIN, BUTTOCK, FINGERS, TOES, HANDS OR FEET. In case of accidental injection, please seek immediate medical treatment. Epinephrine should be used with caution* if you have heart disease or are taking certain medicines that can cause heart-related (cardiac) symptoms.
*
*Tell your doctor* if you have certain medical conditions such as asthma, depression, thyroid disease, Parkinson’s disease, diabetes, high blood pressure and heart disease, have any other medical conditions, are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed. Be sure to also *tell your doctor* all the medicines you take, especially medicines for asthma. If you have certain medical conditions, or take certain medicines, your condition may get worse or you may have longer lasting side effects when you take the EpiPen or EpiPen Jr Auto Injector.

The most common side effects may include increase in heart rate, stronger or irregular heartbeat, sweating, nausea and vomiting, difficulty breathing, paleness, dizziness, weakness or shakiness, headache, apprehension, nervousness or anxiety. These side effects usually go away quickly, especially if you rest.

*Talk to your health care professional to see if EpiPen or EpiPen Jr Auto-Injector is right for you*...."

(Accents mine).

I don't think "talk to your health care professional" means "groan at some bystander willing to shoot epi into you".
As on of the folks the epi could probably kill, my vote is "Whoa there, big fellow!".


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## Christopher (Sep 3, 2013)

mycrofft said:


> Maybe that will help you sleep at night, but first comes "Will it work?" and "Is it needed?".
> 
> People forget that laws and protocols are there for a reason. They may sometimes prove to be outdated or wrongheaded reasons, but there is the germ of an idea there usually sparked by an occasion where something---went---sideways.
> 
> ...



The harms from epi usage in anaphylaxis are overblown, to the point where people die because we're scared to administer it.


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## Wes (Sep 4, 2013)

I could probably write a blog post about Epi-phobia.  :unsure:


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## Akulahawk (Sep 4, 2013)

Something to think about is that Sacramento County EMS used to have a protocol where we had to call for IM Epi if our patient was more than 40 years old and in anaphylaxis. I remember having to call for that order. They changed the protocol as they came to realize that there was a greater harm in withholding the Epi than giving it. Of course we also give diphenhydramine IM or IV/IO in that situation as well. 

Basically they did a competing harms analysis and determined it was better to give than not. Of course we're also to get an order if we have to do 0.1 mg Epi 1:10,000 slow IVP for stridor or hypotension. 

Now would _I_ give an Epi IM shot using someone else's Epi pen? Since I've effectively been off-duty for quite a while, I honestly can say I don't know. I'll cross that bridge if I ever come to it. Give an Epi-Pen shot to someone using their own device? Yep. It's theirs, for their use on themselves...


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## mycrofft (Sep 4, 2013)

Christopher said:


> The harms from epi usage in anaphylaxis are overblown, to the point where people die because we're scared to administer it.



I have atrial fib. Shoot me, and you might as well shoot me. 

Epi is one of out magic trick meds, right up there with glucose and nifedipine titrated to EKG for tachycardia (Am I dating myself? Did I remember right!?). The question is about giving someone you might not have a hx on someone else's meds.

I have to confess I gave a kid a puff of albuteral MDI on a hike when we were too far out and she was shutting up pretty fast. I made sure she didn't get a full dose, she did fine, but I occasionally think how bad that could have gone.


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## mycrofft (Sep 4, 2013)

Akulahawk said:


> Something to think about is that Sacramento County EMS used to have a protocol where we had to call for IM Epi if our patient was more than 40 years old and in anaphylaxis. I remember having to call for that order. They changed the protocol as they came to realize that there was a greater harm in withholding the Epi than giving it. Of course we also give diphenhydramine IM or IV/IO in that situation as well.
> 
> Basically they did a competing harms analysis and determined it was better to give than not. Of course we're also to get an order if we have to do 0.1 mg Epi 1:10,000 slow IVP for stridor or hypotension.
> 
> Now would _I_ give an Epi IM shot using someone else's Epi pen? Since I've effectively been off-duty for quite a while, I honestly can say I don't know. I'll cross that bridge if I ever come to it. Give an Epi-Pen shot to someone using their own device? Yep. It's theirs, for their use on themselves...



"Assisting" people to take their own meds is even taught by the Am Red Cross. Like helping an unconcsious person sign the bar tab maybe.


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## NomadicMedic (Sep 4, 2013)

mycrofft said:


> I have atrial fib. Shoot me, and you might as well shoot me.
> 
> Epi is one of out magic trick meds, right up there with glucose and nifedipine titrated to EKG for tachycardia (Am I dating myself? Did I remember right!?). The question is about giving someone you might not have a hx on someone else's meds.
> 
> I have to confess I gave a kid a puff of albuteral MDI on a hike when we were too far out and she was shutting up pretty fast. I made sure she didn't get a full dose, she did fine, but I occasionally think how bad that could have gone.



If you're jammed up right tight from anaphylaxis, last thing I care about is your afib. You can have some cardizem AFTER I fix the immediate life threat. 

And why were you worried about giving the girl with the reactive airway a puff of beta agonist?


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## randomfire (Sep 4, 2013)

As someone who has suffered anaphylaxis before... if I found that someone had withheld an epipen from me, and I actually survived the incident, I would personally hunt you down so I could watch the life drain from your eyes while I crushed your throat between my hands.


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## rwik123 (Sep 4, 2013)

randomfire said:


> As someone who has suffered anaphylaxis before... if I found that someone had withheld an epipen from me, and I actually survived the incident, I would personally hunt you down so I could watch the life drain from your eyes while I crushed your throat between my hands.


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## Christopher (Sep 5, 2013)

mycrofft said:


> I have atrial fib. Shoot me, and you might as well shoot me.



There is no known association between epinephrine and worse outcomes in anaphylaxis for patients with pre-existing atrial fibrillation.

There is thought to be an association between epinephrine and worse outcomes in anaphylaxis for patients with severe coronary artery disease, however this has not been proven (and may in fact be unrelated to epi administration, i.e. Kounis Syndrome).

If you have any literature to back this claim, I'd like to see it. The best I can bring up is allergic reactions due to envenomations _causing_ atrial fibrillation/flutter which were _resolved_ with IM epi administration!


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## mycrofft (Sep 5, 2013)

DEmedic said:


> If you're jammed up right tight from anaphylaxis, last thing I care about is your afib. You can have some cardizem AFTER I fix the immediate life threat.
> 
> And why were you worried about giving the girl with the reactive airway a puff of beta agonist?



It was an adult MDI and she couldn't tell me what meds she was taking; I had no other drugs and it was a twenty minute hike back to the car and her mom and her meds. (It was very long ago so statute of limitations doesn't apply). 

Call me crazy, but there is a fine line between "She died from anaphylaxis" and "She was dying from anaphylaxis but I hastened it by doing something to/for her". Ethically I can't see a distinction (the so -called "distinction without a difference"), but there was that one point in time where I decided that the risk to the patient was worth it. We cannot trust everyone to make that decision correctly, especially with the shallow preparation they undergo and the cowboy attitude many exhibit.


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## mycrofft (Sep 5, 2013)

Christopher said:


> There is no known association between epinephrine and worse outcomes in anaphylaxis for patients with pre-existing atrial fibrillation.
> 
> There is thought to be an association between epinephrine and worse outcomes in anaphylaxis for patients with severe coronary artery disease, however this has not been proven (and may in fact be unrelated to epi administration, i.e. Kounis Syndrome).
> 
> If you have any literature to back this claim, I'd like to see it. The best I can bring up is allergic reactions due to envenomations _causing_ atrial fibrillation/flutter which were _resolved_ with IM epi administration!



All I know is when I get even the epi in a dental injection, I experience tightness of the chest, my pulse become more irregular, my cardiologist seemed unsurprised and told me no more epi. Not anything to do with anaphylaxis outcome, strictly a cardiac thing. *

This is a prime example of "Probably not going to do anything" versus "In this one case, and in other related ones, it will do something".

(Sort of undermines my continual rants about flagrant inflation of the dangers of peanut allergies, doesn't it?)

Let me elaborate: epi for anaphylaxis is fast acting / short acting gold. Using other people'/s medications is _GENERALLY_ not because of chance of misadventure. 



* "There is no known"...isn't it hard to prove the non-existence of something? Who says no one knows of this happening?


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## mycrofft (Sep 5, 2013)

A one-timer:
http://www.ncbi.nlm.nih.gov/pubmed/19023307

A lay-person columnist:
http://www.boston.com/lifestyle/art...rect.com/science/article/pii/0002870349910108

How about: is the patient on MAO inhibitors, tricyclic psych meds? Anaphylaxis with imminent death may trump possible side effects leading to death, but what is plan B if that occurs?


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