Why do Ambulances Carry Epi-Pens?

Why do ambulances carry Epi-Pens?

You may be asking yourself why I might ask that question. After all, Epinephrine is the first-line medication used for the treatment of anaphylaxis as recommended by scores of organizations and people who know what they’re talking about. It is the definitive treatment for any severe allergic reaction or case of anaphylactic shock. It’s safe to give when it’s needed, has few contraindications in cases of severe allergic reaction, and the earlier it is given in the case of anaphylaxis, the better it works. (1) I should know that, right? Aren’t I a paramedic? Don’t I give epinephrine to my allergy cases?

And if you asked yourself that and somehow I heard it, I’d tell you that you were absolutely right about the epinephrine thing. In fact, it’s been shown that EMTs and Paramedics may need to do a better job of remembering to give epinephrine to patients who need it (1, 2).

But that’s not what I asked. I said nothing about epinephrine. I simply asked why EMTs on ambulances, who presumably are healthcare professionals, use epinephrine auto-injectors because I see absolutely no reason why an Epi-Pen should ever be carried on an ambulance.

Before you start thinking I’m crazy, let’s do some comparisons here:

epi pen

This is an Epi-Pen. It is designed to give the most common dose of epinephrine required by an adult experiencing anaphylaxis, which is 0.3mg of Epinephrine diluted to the 1:1000 concentration (1mg of Epi in 1ml of saline). The auto-injector allows any person to give the correct dose of epinephrine quickly and correctly in an emergency. Patients are able to use this on themselves when needed and anyone can easily give them to a patient when asked to do so. Epi-Pens should be carried by anyone and everyone who is prone to anaphylaxis. They’re positively lifesaving.

They also cost anywhere between $350 and $450 dollars. (Source: Boundtree, EMP, GoodRx.com)

Epinephrine_1-1000_(1)

This is a vial of 1mg of Epi 1:1000, the same used by paramedics and other healthcare providers.

It costs around $4 bucks (Source: Boundtree, EMP)

For those of you who don’t know it is exactly the same medication, just not given automatically. The ampule above requires that a healthcare provider draw up the correct dose of the medication into a syringe using a filter needle and then inject it into the patient using a second needle. The syringe and two needles that are required, one filter needle and one regular 23-25ga needle, cost a few bucks extra. ($12.50 for a box of 100 syringes, $30.15 for a box of 100 filter needles, and $5.49 for a box of 100 25ga hypodermic needles)

To recap the above… if you were an ambulance service you could either treat one patient who was experiencing anaphylactic shock for around $400 using an auto injector… or for around $5 using draw-up epinephrine. Think about that… then let me ask my question again.

Why do ambulances carry Epi-Pens?

In the late 90s came the change from the EMT-A curriculum to the EMT-B curriculum and with it came the thought that the new EMT-B level providers should be able to “Assist with patient-carried Epinephrine” in order to treat anaphylaxis. While EMT-Bs weren’t allowed to carry their own epinephrine in most areas, the thought was that patients who were predisposed to anaphylaxis would have been previously diagnosed by a physician and might be carrying their own epi. The EMT-Bs were trained to use auto-injectors for this reason based on the fact that they would be called to these types of emergencies.

As years passed and severe allergies have seemingly become more prevalent, many organizations started calling for all ambulances to carry their own epinephrine to be able to administer for patients who might not have their own. While paramedics have always carried Epi, most EMT-B staffed ambulances did not and this was shocking to the community activists pushing for change. As such, most states began allowing EMT-Bs to carry and administer Epi-Pen auto-injectors for use on patients who were not previously prescribed them by a physician, many relying on on-line medical control orders prior to their use.

This system worked well for a few years, with the price of the auto-injectors remaining high but affordable. While it has always been a little silly to think that EMT-Bs couldn’t be trusted to give simple Intramuscular (IM) or Subcutaneous (Sub-Q) injections, at least epinephrine was in the hands of people who needed it during emergencies. This has been changing in the last few years, however, as awareness of anaphylaxis and possibly cases of severe anaphylaxis have grown in number. More and more people and organizations are starting to carry Epi-Pens. In fact, many states are now requiring schools to have Epi-Pens on site in accordance with a federal incentive.

This has caused demand for Epi-Pens to go way up, caused supply to diminish to the point of a shortage, and consequentially has caused the price to skyrocket to the currently absurd levels which patients cannot afford. This is something that doesn’t need to happen. My belief is that ambulance services can help to alleviate this problem by simply taking the cheaper and easier option of using drawn-up and injected Epi 1:1000.

While all paramedics and most Intermediate-level or Advanced EMTS have been using drawn-up epinephrine for decades, a good number of EMT-Basics cannot. Some states, such as Wisconsin, New Mexico, Idaho, and Kentucky have started to allow for EMT-Basics to draw up and administer Epi 1:1000 via a syringe but many states, such as Illinois and Connecticut do not allow this and require EMT-Bs to use auto-injectors. I believe that it is absurd to require the use of auto-injectors in the setting of an ambulance and I call for it to end. Take Epi-Pens out of ambulances and replace them with the cheaper and more available ampules of epinephrine 1:1000. There is absolutely no need to require EMTs to use auto-injectors. It is not safer, it is not faster, and it is not a better alternative.

Seriously, if you are a service director, medical director, or state EMS official who believes that your EMT-B level providers aren’t smart or competent enough to draw up and administer epinephrine then you have a much bigger problem that cannot be solved simply by requiring an auto-injector and a call to medical control.

As such, I call upon the National Association of State EMS Officials (https://www.nasemso.org/) and the National Association of EMS Physicians (http://www.naemsp.org/Pages/default.aspx) to help change the archaic and unnecessary practice of requiring EMTs to use Epi-Pen epinephrine auto-injectors and change the necessary standards to allow EMTs to draw up and administer intramuscular epinephrine instead. I also call upon service directors and other EMS professionals to check with their state regulations and begin using drawn-up epi if they are allowed to do so and are not doing it already.

This is a simple change to our industry practices that will have a much bigger effect on the marketplace. We can increase public safety and decrease prices for patients who need epinephrine on their own.

Let’s do this.

 

References:

  1. “Epinephrine: The Drug of Choice for Anaphylaxis – A Statement of the World Allergy Organization” – Stephen F Kemp, Richard F Lockey, corresponding author and F Estelle R Simons, the World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/

 

  1. “Paramedics Often Fail to Give Epinephrine for Anaphylaxis” – Fran Lowry – Medscape Medical News 11/20/2012 – http://www.medscape.com/viewarticle/774828

 

Resources:

1. Obama signs bill to increase EpiPen availability in schools – The Wall Street Journal 11/13/2013 – http://blogs.wsj.com/washwire/2013/11/13/obama-signs-bill-to-increase-epipen-availability-in-schools/d

 

Edited: Epinephrine 1:1000 is 1mg in 1ml, not 1mg in 1000ml

  • An interesting thought for sure, and one that is of particular concern to me as someone who has to manage a budget. However, it is countered by another concern that I have which is the frequency of medication administration errors especially among providers who draw up meds infrequently and must do so under field conditions.

    Now this being the Internet that may read as an attack on the article above, but it is not so at all. I really am curious as to how we might address that concern. Thoughts?

    • Andy

      Very valid points raised. We have addressed that issue thru education and number of drugs carried. Everyone is educated in drug checks and how to administrator via IM, also our FR have to call clinical and they do step by step instructions and EMT have more training in drug administration but still call some for assurance. We only carry epi, otc and nebulized meds in our non-paramedic packs. Hopefully that keeps errors low as they are very different containers.
      Though I have come to back up a crew that gave the IM injection with a blunt drawing up needle. Not really drug error but adverse event linked to poor continuing education. Hope some of that might help, I know people say calling up and getting step by step refresher right then had helped ease everyone.

    • Anne Castioni

      I second your concern for patient safety. Medication errors are an ever increasing problem and proficiency of the EMS provider is highly variable. Who is giving the medication? How often do they administer medication? How frequently do they retrain on medication administration? What is the error rate on all medication administration? I would like to see the numbers if they exist.

      Would we be having this discussion if the price of the EpiPen were not astronomical? Glass while very cheap is not ideally suited for many environments although we have used it for decades. Under the best of circumstances the administration is far from flawless. Consider glass/bacterial contamination and potential for needle stick.

    • trixie77

      -Rommie King County has an excellent protocol for BLS admin of epi, which they have developed a kit for making it essentially fool proof. The cost is about $15. My daughter was diagnosed with Type 1 diabetes at 8 yrs old. By 10 she was using a sliding scale, drawing up appropriate insulin (2 kinds) and self administering her shots. Suffice to say an EMT should have no problem administering a pre measured dose of epi. From what I understand it is commonplace in many areas. I just came across this article while working on a lecture for volunteers re cost saving measures. Sorry CK i rarely miss your blog posts but I’m glad I came across this one – great stuff!

  • Andy

    I work outside the USA as an EMT and can draw up and give IM epi for anaphylaxis, no calls nessisary. I also can nebulize it for angiodemea. Our First Responders are trained to draw up and can give it with a call to clinical. It amazes me that some US services still use auto injectors. I thought the cost alone was prohibitive.
    Drug checks and drawing up are a training skill that is easily taught. Education about anaphylaxis is needed too but if you need to call it doesnt have to be in depth.

  • Andy Ray

    Interesting discussion.

    In uk ambulance services, the Dose for anaphylaxis is 500mcg every 5 mins PRN.

    An epi-pen is 300mcg so would be incorrect dose if given by an ambulance medic!!!

  • Roger W. Dean III

    We don’t carry epi on our units. We have credentialed all BLS providers to give IM epi so we don’t need to waste 1000s of dollars a year on useless (for us) plastic. The BLS provider is hardly even necessary, as we have MICU ambulances and are almost always staffed Medic/Medic and occasionally Medic/FF EMTB. No need to have epi pens as a first responder. We don’t have a nanny system for our FD, we don’t EVER call for orders.

  • John

    Medics in MA use Epi-pens, no drawing it up without med con.

  • CAdvanced

    Some of the more rural areas here in Texas do let EMT-B give epinephrine via the draw up method they just have to be trained and certified by their service to do so, saving the service lots of money. My service for instance allows EMT-B to give it, they just had to spend a couple hours in this class learning proper aseptic and administrative technique.

  • “There is absolutely no need to require EMTs to use auto-injectors. […]it is not faster”

    I have to remain skeptical of this claim without seeing actual evidence. I can’t see how “pull the safety cap and jab it into their leg, hold for ten seconds” is not faster than “put a filtered needle on the syringe, carefully crack the ampule so you don’t cut yourself, draw up the medication, switch the filtered needle for an IM needle, then stick the patient and administer .3 – .5 mg of the 1 mg you just drew up”.

    • laserbeamh

      I absolutely agree about ampules and filter straws and them taking a while. what about multi-dose vials though? no need to switch needles, no glass to worry about. Just draw up and inject.

      • Better, but you still have to open the syringe, open and attach a needle (after finding the appropriate one, which may be a PITA depending on your service), and draw up the epi before you can get to actually injecting it. You’re probably still adding most of a minute to the time an auto-injector would take, unless you have everything packaged together in a kit.

  • Haha. A few years ago the local EMSA made all the agencies go to Epi-pens (both adult and pediatric) because ONE medic administered the wrong dose. When the Epi-pens started to expire a couple of years later, the local EMSA then made all the agencies go back to the glass ampules because it hadn’t realized the Epi-pens cost so much. Typical management.

  • Travis

    I feel the same way about band aids. I would rather not have them on my ambulance. If all you need is a band aid then you don’t need me, and if there is more going on, the band aid will be the least of my concerns.

  • Crist

    EMT’s in WV are able to draw up epi, if they have completed the protocol class. Starting the beginning of the year, we’ll be doing away with epi pens. WV is really starting to trust their EMT’s, our new protocols are pretty exciting!

  • Christine Drinkard

    I’ve worked for 4 services during the past 21 years and all 4 used the ampules.

  • Catherine

    Apologies if this has been addressed in the comments already, however, I feel it is very pertinent. I think the author of this article fails to realize one small but important piece of information. Not all ambulance services are full time urban based departments that live, breathe, and die EMS. There are innumerable rural, volunteer services that rely heavily on people that have lives outside of EMS including such things as, oh, let’s say a real full-time job, children, children’s activities, grocery shopping, church, church activities, etc. Let’s not forget that the closest grocery store is 30 miles away. Add to that the fact these services run as few as 200/300 calls a year, total. Oh, and in some states all that is required on a truck is 1 EMT, the other can in fact be an EMR. When your total call volume for a year as a volunteer is maybe 20 calls and 19 of those are ridiculous non-emergent calls, it is extremely difficult to remain proficient at anything that you do not use on a constant or somewhat regular basis.

    I understand that if you’ve only ever worked urban EMS you would not understand the commitment that rural volunteers make to even remain certified, let alone proficient with all the skills in their scope. (Ever consider that continuing education in and of itself is difficult to obtain in certain areas due to lack of people willing/able to teach?) While those of us in the so-called “fly-over states” are often seen as hillbillies and rednecks, the truth of the matter is that we, too, are tax-payers, we are hard-working Americans, we are white-collar, we are blue-collar, we are sometimes dirt-collar, and we all deserve to have an ambulance service available to respond to our emergencies, too. So what if those ambulances are manned by volunteers?

    It is unfortunate but an inescapable reality that not all services can function under the same umbrella that urban services function under. Articles like this that seem to present the urban EMS system as the only consideration is completely ignorant.

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  • Braden Peters

    The filter needles is not even necessary. You can draw up the epinephrine from an ampule and give it using the same needle. This is routine practice in most of the world, including Canadian EMS. Unfortunately, the EMR (EMT-B) level here also does not have epi, or if they do, it is in an autoinjector. I 100% agree that all EMS providers should be capable of drawing up and administering IM medication.

    As for the risk of medication errors, that is just a training and education issue. It would not be difficult to implement routine CME for anaphylaxis into ongoing departmental training. If a portion the time that was taken teaching spinal immobilization in EMR/EMT-B classes was instead used to teach some basic physiology, pathophysiology and pharmacology, and in turn, the use of the BLS medications like IM epi many of the issues would resolve.
    It is stupid to think that one needs to be an ALS level provider to figure out how to read a syringe.
    The risk of a BLS provider not drawing up the right dose is the same as the risk of an ALS provider doing the same thing. IM epi is IM epi…

    Lastly, if ALL else failed, the provider could simply draw up 0.3 mg (0.3 mL) or 0.15 mg (mL) for peds and give that IM if they were unable to do the very simple math to calculate the dose (which would be a rare circumstance indeed). That is the same dose as the epi pens but far less expensive.

  • totwtytr

    It’s definitely faster and it’s accurate. There’s really no down side to it at all. Other than the fact that some people give it when it’s not needed, but that’s not dose related.

  • Interesting. I’ve never heard of ambulances carrying EpiPens. I’ve worked in Wisconsin and Tennessee. Both places have always allowed EMT-B to draw up from Epi ampules. However, when seconds count, I could see EpiPens being something EMTs and Paramedics could benefit from. It’s just costly.

  • Amanda Millisa Hargis

    I tend to strongly disagree with you on this. They absolutely MUST have an Epipen available. By the time the ambulance gets there its already to a critical point if there was no medication available. The time it takes to secure an IV and get that injection in them means death for the patient. Period. Your idea doesn’t work in real life scenarios.

  • Doin’

    I applaud you CKEMTP for your insight and thinking outside of the box. I am an EMTB and trained to only assist the patient use his/her own epi pen. The ambulance service I run with doesn’t allow EMTB to administer any medication other than oxygen. I also am allergic to all types of bee stings and have had to use an epi pen quite frequently on myself. I am frequently in and out of multiple vehicles and to carry an epi pen on my person seems impossible. Yesterday I went to the local pharmacy to see if I could get 8 more epi pens (1 for each of the vehicles I am frequently in) and I was surprised at how expensive they have gotten. The first time I purchased a 2 pack it cost me $10 through my insurance. The pharmacist told me yesterday that I would need to pay $60 for the first 2 pack and $250 for each 2 pack thereafter. That is a lot of money just setting in the glove (hopefully) for a just in case I need it situation and then to get them with only 1 year left before expiration?
    Two summers ago I needed to use the epi pen 3 times. Last year I got lucky and didn’t need it once. But now I have all of the expired date epi pens that need to be replaced. Something needs to happen with the cost.

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  • riedmur

    The Epi-pen probably costs about $25 and the other $375 is for insurance premiums for the one patient who dies after the injection and the family sues for $10 million.

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