Paramedics Often Fail to Give Epinephrine for Anaphylaxis

[Aidey]

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.

 

[OfficerEvenEMT]

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.

 

[VFlutter]

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.

 

[Aidey]

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.

 

[VFlutter]

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.

 

[OfficerEvenEMT]

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?

 

[OfficerEvenEMT]

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.

 

[Shishkabob]

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.

 

[Wheel]

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.

 

[Tigger]

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.

 

[reaper]

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.

 

[OfficerEvenEMT]

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.

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.

 

[NYMedic828]

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

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

 

[VFlutter]

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.

 

[reaper]

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?

 

[OfficerEvenEMT]

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.

 

[OfficerEvenEMT]

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.

 

[NYMedic828]

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.

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.

 

[RocketMedic]

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!

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?

 

[OfficerEvenEMT]

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.