Mom wants ALL City Ambulances to carry Epi-Pens

[BFD1054 1,552]

From the New York Daily News on Monday:

http://www.nydailynews.com/ny_local/bronx/...urges_ci-1.html

[SRS131EMTFF 471]

Who are we/they kidding.........

Why would they not keep an epi-pen on all rigs......

This is a travesty and New York should be ashamed of itself, this is a medical innovation that has saved thousands of lives and requires little medical training to use. They are very lucky more people have not died because of this.

I have used one on myself when I was 10 when I needed it, if I can do it then some 18 year old fresh off the test should be able to do it, let alone a BLS tour in an EMS system with 1,000,000 calls a year.

They carry epi-pens on BLS buses in Westchester, why not on a BLS bus in the city is beyond me.

[Guest]

They don't carry Epi-pens in NYC?!

[Guest]

Do we really know if 33% is correct lets not jump down the wrong path ???? Also if you know your allergic shouldn't you carry an epi-pen with you at all times???

Edited February 5, 2009 by JHK3605

[SRS131EMTFF 471]

Should someone with heart problems carry a real AED with them where ever they go.......

While it would be nice for everyone with these issues to carry an epi-pen it is very easy to forget it, lose it, have one expire before a replacement can be obtained or you could be incapacitated and unable to inform those you have it or use it yourself.

Even if it is 99% with it that 1% needs to be addressed....

Apparently little Johnny Q's public day camp is better equipped to deal with anaphylactic emergencies than a BLS tour is considering almost every summer camp I have worked at or was a camper at had a well established, trained and ready staff of nurses and EMTs ready to dispense this life saving medication.

Edited February 5, 2009 by bvfdjc316

[FFD941 20]

Should someone with heart problems carry a real AED with them where ever they go.......

If someone is diagnosed with a cardiac related problem that is that severe they will have an internal defib implanted.

I'm sorry I disagree here, if you have a medical problem and have been prescribed the proper preventative/reactive medications and you do not carry them, then you are at fault not me.

I do however, agree that it's crazy to think that a NYS certifed ambulance doesn't carry the appropriate equipment.

Anyone know if they carry Atropine?

Edited February 5, 2009 by FFD941

[20y2 43]

There are still ambulances that don't carry AEDs, why would you think that every ambulance would carry Epi-Pens?

[CTFF 65]

I'm sorry I disagree here, if you have a medical problem and have been prescribed the proper preventative/reactive medications and you do not carry them, then you are at fault not me.

What about people who do not know they are allergic to something? It does not happen often but it does happen where people have an adverse reaction and did not know they had an issue prior to exposure.

Edited February 5, 2009 by CTFF

[Goose 188]

Who are we/they kidding.........

Why would they not keep an epi-pen on all rigs......

This is a travesty and New York should be ashamed of itself, this is a medical innovation that has saved thousands of lives and requires little medical training to use. They are very lucky more people have not died because of this.

I have used one on myself when I was 10 when I needed it, if I can do it then some 18 year old fresh off the test should be able to do it, let alone a BLS tour in an EMS system with 1,000,000 calls a year.

They carry epi-pens on BLS buses in Westchester, why not on a BLS bus in the city is beyond me.

First of all, cool your jets. The auto-injector program is available to all agencies if they choose to participate - they are not required to by any state regulations.

Comparing Westchester and NYC is like apples and oranges. At least the ambulances in NYC respond to jobs within ~6 minutes. So, hey, carry all the epi you want but when a good portion of those 150 Westchester 911 ambulances never leave the garage in a timely fashion what difference does it make?

While i couldn't tell you why the FDNY does not have auto injectors, it may very well have to do with developing the proper protocol, developing QA/QI, rolling out the employees and purchasing the proper equipment. You are dealing with a much larger and far more complex beast, it takes time and lots of cash (which the city does not have, mind you) to make this sort of stuff a reality.

Who knows, it may even be in the works.

[SRS131EMTFF 471]

I was using Westchester as an example a BLS agency with much fewer runs of having epi-pens, I could have easily said any urban/rural rescue squad here in Vermont. Which I should have considering that would be a better example of volunteer agencies with short response times and low call volume all carrying epi-pens at the BLS level.

[nycemt728 49]

To put together what several people have said here:

- NYS part 800 does not make it a requirement to carry Epi auto-injectors.

- Similarty NYS does not require an AED

- Individual agencies may elect to carry Epi pens if they prove to the state they have a proper training program and protocols in place

- Several VACs in NYC have chosen to put that program in place

Carrying epi can be be expensive not only as a start up cost ( epi and epi jrs for each truck) there is the constant cost of replacement before expiration

In NYC, with decently accessible ALS, close hospitals, and some agencies already carrying, it may very well be sufficient. While I'm sure the numbers are accurate, the councilwoman and the article provide no correlation between the number and any adverse effects to patients. Now, would having EPI on every truck be a plus, abselutely, but especially in times of fiscal crisis is it necessary?

Edited February 5, 2009 by nycemt728

[ny10570 745]

Wow, do I have some problems here. First off, this article is about someone who want Epi Pens based on the fact that 2/3 of all FDNy buses are without Epi. This isn't about a case of a death or injury as a result of this set up.

Epi pens save lives in the hand of the those with the allergy. As an EMT in NYS you are only allowed to use an Epi pen on someone suffering from Anaphylaxis who has been prescribed an Epi pen. How many people does this even apply to? Most people with this severe of an allergy are very good at carrying their Pen, and in NYS you are allowed to assist any Pt in administering their own medication.

Lets start the NYC/Westchester comparison. How often do Westchester ambulances beat ALS to calls? How many times have Epi pens been used by BLS units?

If you were stuck treating a patient w/out epi, what would happen? First, the issue is respiratory failure due to exhaustion. The narrowing airways result in increased effort leading to respiratory failure. BLS ventilation, while not ideal is capable of maintaining oxygenation until ALS arrival or transport to definitive care.

Only 1/3 of all FDNY buses carry Epi because thats how many ALS units we run. As far as getting Epi to the right people, we have EMD to address that issue and ensure that ALS is assigned to every possible allergic reaction. As an EMT I handled 1 bad anaphylactic w/out ALS and only because the caller said "I feel sick" then hung up. I requested ALS who was 5 minutes out. I was 5 minutes from Monty so I split and calmly transported. Within minutes of IV epi she was talking and thanking everyone. This was the first time it had happened to her so she still wouldn't have earned BLS Epi. As a medic the vast majority of my Anaphylactic calls are people who claim dyspnea and a an allergy without an actual anaphylactic reaction.

In short FDNY does not cary Epi auto injectors because there is no evidence of need. The system currently in place addresses this particular set of needs.

The only Atropine injectors are part of our WMD kits, of which we now carry Duodote (Atropine and 2-Pam in a single injector).

[NWFDMedic 58]

Actually, the BLS protocol does not limit Epi-pen use to patients with a known allergy and a prescription. Direct from the NYS BLS Protocols:

" A. If the patient is having severe respiratory distress or hypoperfusion and has been

prescribed an epinephrine auto injector, assist the patient in administering the

epinephrine. If the patient’s auto injector is not available or is expired, and the

EMS agency carries an epinephrine auto injector, administer the epinephrine as

authorized by the agency’s medical director.

B. If the patient has not been prescribed an epinephrine auto injector, begin transport

and contact Medical Control for authorization to administer epinephrine if

available."

I don't think the purchase of Epi-pens would be a huge burden on FDNY and the fiscal portion of actually maintaining the medications would be a drop in the bucket. The cost of training, continuing medical education, etc., could be a HUGE factor.

Those who argue that there is a hospital on every street corner and 100+ ALS trucks in the city don't make a great argument, in my opinion. How many times will the BLS crew get to the scene, have to walk up 8 to 10 flights of stairs (if not more), and get to a patient who is having a severe reaction. Then a request for ALS, assuming a unit is close and you have good communications with dispatch, would be another 5-8 minutes, plus add in the walk up the stairs (maybe split the difference as the BLS crew should be moving), etc. In these cases where swift action is crucial, I would hope that my brothers and sisters in the FDNY have the proper tools available to them. Bagging a patient may help to bridge the gap, but it is not always effective.

[STAT213 332]

Ok. Raise your hands if you have EVER seen a TRUE anaphylactic reaction...

And, I don't mean some itching, or some wheezes...a TRUE life or death situation.

[NWFDMedic 58]

Ok. Raise your hands if you have EVER seen a TRUE anaphylactic reaction...

And, I don't mean some itching, or some wheezes...a TRUE life or death situation.

I have seen several. I can specifically remember a patient last year who was on that borderline of being intubated when the epi/benadryl finally started to turn him around. Certainly more of our calls are of the less than anaphylactic variety, but there are several factors:

1. In the Hudson Valley, our patients usually have better access to medical care. Move the focus to a place like NYC with several areas of patients that have less than optimal access to medical care, and you'll see more patients without proper remedies.

2. A good number of our summer calls are at facilities that have access to Epi-pens.

3. Most BLS services in the Hudson Valley carry Epi-pens and begin to turn the reaction before I get there.

[x129K 1,393]

Ok. Raise your hands if you have EVER seen a TRUE anaphylactic reaction...

And, I don't mean some itching, or some wheezes...a TRUE life or death situation.

I was one......twice

[minivac 0]

As a person who is allergic to nuts and has many family members who are also, I am shoked to find out that not all NYC ambulances carry epi pens. It i an extreamly important medicine that should availible everywhere. I woulnt mine payig a few extra dollars a month in taxes to make sure that there is an epi pen on every rig in NYc

[NYRangers30 1]

I don't really understand why they font carry them. They are small enough.

[helicopper 1,050]

At a time when the city is considering cutting 30 BLS tours per day citywide, the fiscal impact of anything is a valid question. Does anyone know the numbers of acute anaphylaxis or other cases that would benefit from the administration of epinephrine that do not receive ALS responses?

I'm guessing that an anaphylaxis call is going to be a higher priority and more often than not receive an ALS response so the epi is there in one form or another. In the event that an ALS response is not available, how fast could a BLS unit in the 5 boros be at a hospital where the epi is available?

I don't think that it is as big a deal as its being made out to be. Would I like to see epi on every ambulance? Not unless the training, QI/QA, and response times support its use. As Goose said, if the ambulance takes 30 minutes to get there, who cares what its carrying.

[RNMedic08 0]

My frist call as a Medic student in AFD. The call came in as a "unknown medical" then updated to "allergic reaction" when my Medic preceptor and I entered the home the husband was found lying on the floor between the sink and refrigerator wheezing, diaphoretic, tachycardic and covered in hives. He had been stung by 5 bees. Never had an allergy before.....

Also I have a child who ate th age of 5 had an anaphylactic reaction to peanuts and she had been eating peanut butter since an infant. Luckily I have an epi pen for her at school at CCD and a spare that she carries when she leaves the house and not under my direct supervision.......

So in answer many of us HAVE seen first hand a TRUE anaphylactic reaction.

[Goose 188]

At a time when the city is considering cutting 30 BLS tours per day citywide, the fiscal impact of anything is a valid question. Does anyone know the numbers of acute anaphylaxis or other cases that would benefit from the administration of epinephrine that do not receive ALS responses?

I'm guessing that an anaphylaxis call is going to be a higher priority and more often than not receive an ALS response so the epi is there in one form or another. In the event that an ALS response is not available, how fast could a BLS unit in the 5 boros be at a hospital where the epi is available?

I don't think that it is as big a deal as its being made out to be. Would I like to see epi on every ambulance? Not unless the training, QI/QA, and response times support its use. As Goose said, if the ambulance takes 30 minutes to get there, who cares what its carrying.

Chris, NY10570 said that if a job is flagged by EMD as anaphylaxis's ALS is assigned. Maybe NY can clarify if that means ALS is assigned along with a presumably closer BLS unit?

[NWFDMedic 58]

Also I have a child who ate th age of 5 had an anaphylactic reaction to peanuts and she had been eating peanut butter since an infant. Luckily I have an epi pen for her at school at CCD and a spare that she carries when she leaves the house and not under my direct supervision.......

So in answer many of us HAVE seen first hand a TRUE anaphylactic reaction.

Lisa, you are hitting the nail right on the head here. You are a responsible mother and have access to medical care and insurance. The population demographic in NYC is not likely to have the same resources. These are not situations where you can wait the extra 10 or 15 minutes to get the care.

The only acceptable explanation from an FDNY standpoint would be that EMD is catching the greatest (95%+) of these calls and sending ALS trucks AND the fiscal repercussions of training every EMT are cost limiting to handle that other 5%.

We all know what will happen here. Someone of political influence will die or someone that has family that will raise enough stink to get activists involved. Then and only then will you see action.

[ny10570 745]

In NYC any call that qualifies as an Anaphylactic an ALS ambulance is assigned. If the ALS is determined to be greater than 10 minutes away a closer BLS is assigned. A BLS on a lower priority sick, abd pain, injury, etc can be preempted off their job and assigned to the Anaphylactic if they are the closest unit.

I still don't see the pressing need for Epi Pens in all BLS in NYC. BLS interventions are very effective in the majority of Anaphylaxis patients. It is a rare situation where there isn't a medic or a hospital within 10 minutes of you. Epi is not a drug without risks and the cost of training and stocking is substantial. You're talking more than 160 units plus restock supplies and training 2000 people. To get new drugs added we have to horse trade with the department or demonstrate a pressing need for the medication. While many people have stories where Epi pens saved the day, no one has a story about a death as a result of lack of access. While I hate reactive medicine every decision has to pass a cost benefit analysis. There is only so much money to go around, and there are other things to spend money on that will have a greater affect on more people.

[Bnechis 3,961]

and the cost of training and stocking is substantial. You're talking more than 160 units plus restock supplies and training 2000 people. There is only so much money to go around, and there are other things to spend money on that will have a greater affect on more people.

Having just had to replace all of ours (due to expiration), the cost for 160 units is approx $41,000 (not including restock, training, etc.) and they expiration dates they are shipping direct for the drug co is 14-16 months

[Guest Loud412]

FDNY EMD assigns a priority level of 2 to every call that comes in and gets classified as an anaphalactic reaction. Priority level is 1-8, with 1 being the highest priority, including cardiac arrest, choking, hanging, and drowning. So these calls are the second highest prioity along with calls classified as unconcious, status epilepticus, difficulty breathing, and asthma. A person with a possible cardiac condition is actualy classified a lower priority than people with the above listed condition. And to reiterate what someone said above als is always assigned to this call type as long as its available (and it usualy is). If the dispach software determins that the als unit is further than 10 minuts away based on the last known gps location, the closest bls unit is also assigned. To go along with that, a CFR-D engine (which are usualy a lot closer than either the als or bls) is also assigned regardless of how far either als or bls units may be. Now in most of Manhattan, you are never more than 6-8 minuts away from the closest hospital to the scene. And as long as the proper notification is made to the hospital prior to arrival, the pt should be recieving the life saving treatment he/she needs within minuts of arrival at the ED.

[Guest]

Since all ambulances should have epi-pens maybe they should put them on all engines and trucks also as they go to calls and may get there before an ambulance oh what about the cops they might get there first too?????? yes im being sarcastic

[Guest]

Real cute... They don't even want to keep their CFR-D's, god forbid we make them train on epi pens!

I think we're beating a dead horse here guys and in some aspects comparing apples to oranges. Lets face it the geographic diversity between the Hudson valley remac region and the 5 boroughs is quite different, if not extreme. I can agree with both sides of the argument but that's because everyone is speaking with their particular area in mine. The remac protocols are different, topography is different, and ease of access to a slew of emergency resources is night and day. Coming from both sides of ye old fence; I see nothing wrong with the FDNY EMS methods. All the facts have been written earlier by others. As for our northern brethren, It makes perfect sense the way its being done.

Also a side note; The article is flawed in many ways, re-read it and then formulate some thoughts. Here: "If you call 911, you only have about a 33% chance of getting one with epinephrine," Menin said. "Those odds are unacceptable." Sure I have a 33% chance of getting ALS but if you say the words allergic reaction or cant breath or face swollen, you're 100% guaranteed ALS. The Daily News has a lovely way of always making city agencies look to be the bad guys. It's a shame what media has become. Anyway I'm done flogging this dead horse.