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 theyâ€™re talking about. It is the definitive treatment for any severe allergic reaction or case of anaphylactic shock. Itâ€™s safe to give when itâ€™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? Arenâ€™t I a paramedic? Donâ€™t I give epinephrine to my allergy cases?
And if you asked yourself that and somehow I heard it, Iâ€™d tell you that you were absolutely right about the epinephrine thing. In fact, itâ€™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 thatâ€™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 Iâ€™m crazy, letâ€™s do some comparisons here:
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. Theyâ€™re positively lifesaving.
This is a vial of 1mg of Epi 1:1000, the same used by paramedics and other healthcare providers.
For those of you who donâ€™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 aboveâ€¦ if you were an ambulance service you could either treat one patient who was experiencing anaphylactic shock for around $400 using an auto injectorâ€¦ or for around $5 using draw-up epinephrine. Think about thatâ€¦ 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 â€œAssist with patient-carried Epinephrineâ€ in order to treat anaphylaxis. While EMT-Bs werenâ€™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 couldnâ€™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 doesnâ€™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 arenâ€™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.
Letâ€™s do this.
- â€œEpinephrine: The Drug of Choice for Anaphylaxis – A Statement of the World Allergy Organizationâ€ – 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/
- â€œParamedics Often Fail to Give Epinephrine for Anaphylaxisâ€ – Fran Lowry – Medscape Medical News 11/20/2012 – http://www.medscape.com/viewarticle/774828
1. Obama signs bill to increase EpiPen availability in schools â€“ 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