Austin/ County and MPDS

[Guest guest]

Interesting article.

-Wes Ogilvie, MPA, JD, Lic. P./NREMT-P

-Austin, Texas

Should dispatchers tell callers how to give allergic reaction medication?

Austin EMS officials push for national standard on giving instructions over

the phone.

By _Tony Plohetski_

(http://www.statesman.com/news/content/news/stories/local/04/13/mailto:tplohetsk\

i (AT) statesman (DOT) com)

AMERICAN-STATESMAN STAFF

Monday, April 13, 2009

On the day she dialed 911 in November, the caller knew from a previous

near-fatal experience that her 80-year-old husband was probably having a severe

allergic reaction and needed an urgent dose of a potentially life-saving

drug.

She told the dispatcher, a trained paramedic, that she had a shot of

epinephrine at hand but wasn't sure how to give it.

Under Austin- County Emergency Medical Services rules, the dispatcher

wasn't supposed to tell her.

The Nov. 29 call and several others like it recently have prompted a debate

within EMS about whether dispatchers should coach 911 callers in how to

administer epinephrine, a prescription drug commonly given to patients with

severe allergies to stall reactions. Doctors say the medicine can prevent

cardiac arrest but can be life-threatening if given in the wrong

circumstances.

Some dispatchers say that if they are confident a patient is having a

reaction, they should be able to tell untrained callers how to administer the

drug, which is given through an injection with an EpiPen. However, others say

EMS could be held liable if the drug is given incorrectly or if a

patient's condition is misdiagnosed.

Officials said they have had about four calls in recent weeks in which

callers did not know how to use EpiPens or couldn't think clearly enough to

remember the directions. EMS officials would not release the identities of the

patients, including the 80-year-old man, citing medical privacy laws.

" We want to be able to provide instructions when there is a need for that, "

said Austin- County EMS Director Ernie , whose agency is

pushing to create a national standard for telephone instructions for using

EpiPens, which are disposable, pen-shaped automatic injection devices

containing a single dose. " In a situation where someone is having a severe al

lergic reaction, we want to be able to do something for them while they are on

the phone. "

Last year, EMS officials received 666 calls about allergic reactions, which

was 22 more calls than in 2007.

EMS dispatchers are bound by written protocols adopted from a national

agency about what they can tell callers and how many crews to send to a scene.

The protocols include certain life-saving instructions, such as how to help

a choking victim or administer CPR.

However, the protocols do not include instructions for how to give most

medications, including with EpiPens.

EMS officials said epinephrine is generally the only drug they would be

comfortable telling callers how to administer by phone because it is one of

the few medications paramedics use on the street. They already have

experience in giving it, and the process is generally not complicated, they

said.

Other drugs — insulin, for instance — are much more patient-specific and

are never administered by paramedics, officials said.

Dispatchers are evaluated by supervisors and officials for the National

Academies of Emergency Medical Dispatch, which accredits the agency's

dispatching process, on how well they follow the written script. Dispatchers for

Austin's police and fire departments have similar protocols.

Police dispatchers use guidelines developed by department officials, who

routinely evaluate and change them if they determine there are ways to

improve service.

Fire dispatchers rely on protocols developed by the National Academies of

Emergency Medical Dispatch but have not sought accreditation from the

agency.

A group of Fire Department dispatchers also has begun challenging certain

guidelines they must use, saying that they lack room for dispatcher

discretion. Assistant Fire Chief Jim , the department's chief of staff,

said

fire officials are reviewing whether they should alter some protocols.

But because EMS officials want to maintain the national dispatch

accreditation, those dispatchers have the least flexibility in how they respond

to

emergencies.

Academy officials could not be reached for comment.

After the Nov. 29 allergic reaction call to EMS, communications officials

sent a bulletin to dispatchers, saying, " If your caller has an EpiPen and

requests directions on using that pen, you MAY NOT provide instructions. "

It said that as dispatchers, they have no way of making sure that the

medication was prescribed to the particular patient, that the drug has not

expired and that the correct dose will be given. It also said that patients who

were prescribed the medication should have been shown how to inject it.

The dispatcher, Gerrod Frame, sent an e-mail to his supervisors: " Does this

mean that during one of the average two 911 calls that a mother will place

in her lifetime, (she) has to remember how to operate that 'injector

thingy' that the doc gave them a year ago? " Frame asked. " What defines

instructions? Looking for the expiration date? Reminding them to hold it 10

seconds? "

EMS officials, after receiving the e-mail, put together a group of

dispatchers, medics and other experts to figure out if they wanted to begin

lobbying the national academy to change the protocols.

The group has decided to apply for a rule change, which they said would

create the first national standard in dispatch instructions for EpiPens. They

said they hope to submit the application this month.

" My feeling is that it wouldn't require much additional instructions for

the communications folks to be able to relay, over the telephone, exactly

what to do, " said Dr. Kempema, interim EMS medical director.

However, Dr. Bledsoe, a nationally known EMS expert who lives in

Midlothian, said he would have concerns.

" The chances of the patient being harmed are pretty small, but there is

always going to be that patient that misrepresents or misunderstands what's

going on, " he said. " Without laying your eyes on them, you are just taking

too big of a gamble. Everything in medicine is benefit versus risk. What is

going to be the harm in waiting four to six minutes for an ambulance? "

In the call involving the 80-year-old man, his wife talked with Frame for

several seconds as she struggled to figure out how to use the EpiPen.

As she wrestled with it, paramedics showed up and took the patient to Seton

Medical Center. His condition was not considered life-threatening when he

arrived.