Proposed WI Law Highlights Need for Ambulances To Ditch Epi-Pens

Epinephrine_1-1000_(1)Some recent proposed legislation here in the State of Wisconsin has gotten me back of the topic of ambulances carrying Epi-Pens. The bill, sponsored by Republican lawmakers, seeks to allow “camps, colleges, day care facilities, restaurants and other businesses to the list of entities allowed to carry and administer” epinephrine via auto-injector.

You can read the full article about the bill from the Associated Press here and in many other places on the web if you would like for more information. Basically, the bill states that if you start to have an allergic reaction to something at your local café the fry cook is going to be empowered to jab you in the leg (hopefully) with an Epi-Pen to help your swelling come down. For better or worse, and I don’t pretend that there aren’t problems with this whole popular push for epinephrine administration, I support this change because I believe that overall the proliferation of public epinephrine is a net positive in spite of the potential for harm from laypersons misdiagnosing anaphylaxis and giving epinephrine to a stranger inappropriately. Epi-Pens are not toys, after all.

However, the consideration of this bill makes one of my previous positions on epinephrine auto-injectors all the more poignant.

In December of 2014 I asked the question “Why do Ambulances Carry Epi-Pens?” in a post here on this blog. In the piece, I stated my firm belief that no ambulance in the US should be required to, or choose to carry the epinephrine auto-injectors commonly known by the trade name “Epi-Pen.” I still very much believe that carrying Epi-Pens on an ambulance is irresponsible, unnecessary, and harmful.

Of course, before you get out your pitchforks and torches, my point was that because ambulances usually are staffed by trained and competent medical providers, ambulances should carry vials of epinephrine 1:1000 along with 1cc syringes and needles and draw up the epinephrine to inject manually instead. The auto-injectors are intended for use by patients and other laypersons who need to inject epinephrine in response to the rapid onset of a severe anaphylactic reaction where seconds truly count and an emergency medical response is too-many minutes away.

My point in that article, for the Too Long: Didn’t Read (TL:DR) crowd is this: Epinephrine is good when indicated for severe allergic reactions and anaphylaxis and should be carried by every ambulance and EMS response unit. However, by requiring EMS providers to use and/or carry the auto-injectors instead of drawing up and injecting epinephrine from a vial, you’re actually hurting patients who then have to compete with the increased demand for the Epi-Pens by EMS agencies which creates a much higher demand in the marketplace and results in astronomically higher prices for and shortages of the medication for patients in need.

To be clear: Epinephrine = good. Access to epinephrine = also good. Requiring ambulances and EMS professionals to carry epinephrine auto-injectors due to arcane and outdated legislation or rules = bad. States or regions that require EMS providers use auto-injectors = part of the problem.

Thankfully the State of Wisconsin, who through this bill is going to again increase demand for and therefore the price of Epi-Pens, has already allowed their EMS agencies at the EMT-B level and above to use drawn-up epi. I would suggest to the State that they further incentivize EMS provider agencies to use that option instead of continuing to waste money on unnecessary auto-injectors in order to help balance patient costs and keep the pens in the hands of the patients where they are truly needed.

if you’re a person who has control over this kind of stuff, or a person who wants to make sure that patients have access to epinephrine when they need it, you should consider talking to the powers that be in your state or locality to make sure your area’s ambulances, at any level of care, are using epinephrine 1:1000 from a vial that they draw up and inject rather than spending all that money on auto-injectors which are wholly unnecessary for them at their level of training.

If you’d like more on my reasoning, including a breakdown of the costs and projected savings for EMS agencies based on 12/2014 pricing ($400 for an Epi-Pen vs. $4 for a vial of Epi, a syringe, and two needles) along with references, go ahead a click through to the earlier post “Why Do Ambulances Carry Epi-Pens?” for a good explanation you can share.

Remember, Epinephrine is good. Access to Epi is also good. Epi-Pens are great for patients… but stop putting them on ambulances. Let professionals use the tools available to them for the benefit of patients in need.

  • Robert Hutson

    Any decision to place auto-injectors on ambulances or not should be left to the medical direction of the EMS service. State law should have nothing to say about what medications will or will not be carried on an ambulance. State law should only give the authorization to competent medical direction to make these decisions.

  • Aaron Michael White

    What about the fact that many rural services may only have Emts who can administer an epiPen but can’t draw it up? Until ems regulators become progressive with their approach to common sense solutions, epipens and other simplified devices have a place in an ambulance.

    • croaker260

      Before the era of auto injectors (1980s and early 1990’s) EMTs were trained in this in many states and in the military. Its not a big deal.

    • Scott Ziegler

      Fact: In WI all EMT’s are trained to do this and must refresh it regularly even if their service has only Epi-pens. It’s lazy administrators and medical directors.

      • Barefoot in MN

        Then I do wish that fact was up-front and crystal-clear in the original (this) post. I kept shaking my head in disbelief & consternation at the ideas, because I am in northern rural Minnesota where the vast majority of EMS care is delivered by EMR’s and EMT’s… who are NOT usually trained in injecting anything. Anything that breaks the skin — in Minnesota — is paramedic territory. (and don’t just glibly say “so become a paramedic then”.) Any service that wants to administer anything by injection must 1)be BLS — which leaves out a number of smaller agencies– and 2)have their medical director approve a variance. I kept imagining all the people who would be far more likely to die just because you want to lower the price of epi-pens. You want a lower price for patients? Easy, just have the dear govt take over the epi manufacturing industry & impose price controls… oh wait — everything the govt touches becomes more expensive & less efficient. Okay nevermind. ….I believe government ought to be a last resort, not the first resort, for anything. Wanting to lower the price of epi-pens for the patient paying out-of-pocket is a noble goal, but the method of using government as the FIRST line of attack is a recipe for “unintended consequences” – which implies “unforseeable results” but in actuality means “foreseable but ignored results”. Hmph! If we ask the NAEMT people for their assistance we may get some ideas; grassroots, people-initiated ideas that will work better than stuff imposed from above by clueless politicians.

  • Vik Singh

    This is a rather interesting move. Here in Australia (particularly Queensland and New South Wales), adrenaline auto-injectors are being stocked into hospital resuscitation trolleys and ambulance medication bags. This is due to the quick and easy nature of being able to administer adrenaline in anaphylaxis. However, in Australia, unless you have been diagnosed and prescribed an adrenaline auto-injector, you cannot have one. Thus, supply tends to be rather good.

    • Troy

      Not quite, auto injectors are a schedule 3 medication. No prescription required. Still come at a cost of $100+ per unit.

    • Barefoot in MN

      in Minnesota, at least, epi-pens are only available to the public by prescription .

  • Dan Kutz Sr.

    As an EMT in the state of Ct, we are not allowed to carry syringes and vials of any meds. There fore we cary Epi-pen auto injectors in our Ambulances. We must get med control on the phone/radio and talk to a MD and explain our situation to him/her for permission to use it. Only Paramedics carry epi in vials and have standing order to use W/O prior med control.

    • Chuck Stine

      Please give correct information, depending on region and you Med Control you can have standing orders as is the case in at least the western half of the state. Know your protocols and online / offline med control.

  • croaker260

    The funny thing is that before the era of auto injectors, EMTs in TN …drew up epinephrine. Considering the cost, this not only makes sense, but makes $ense too.

  • Valerie Schoen

    You’re making sense. I’ll go as far to way we should do the same with narcan and administer it to make sure the patient is breathing and nothing more (none of this I’ll ruin their high retribution out there). Oh wait, it would mean more medical oversight, more training and retraining, more paying attention to what is in stock and if it disappears. Now I know why……. Sad. They should listen to you. Me too!

  • tx_k

    Let’s be real, there is no shortage of epinephrine or plastic. The demand for epi pens does not equal a shortage of supply, you are simply ordering more pens to be made. Every ambulance in the country could order an epi pen. The manufacturer would make a fortune, sure. But there would be no increase in cost for the average patient.

    There’s already another epi auto injector company selling these things now. Auvi-Q. Keep ordering them, the market will supply.

  • Joseph Moore

    A short time ago, I received a coupon for a free epi-pen, and since my wife is allergic to many things including bee stings, nuts, latex, etc., I sent it to our pharmacy to get a “free” epi-pen. When all was said and done, the epi-pen was not free, so I did the research on the costs of the “free” epi-pen, with insurance, the cost was almost $200. Then I investigated the time necessary to teach the skills necessary for an EMT to draw up the medication and administer it using an insulin syringe. The total time including the practical skills session was two hours of training. I am a paramedic instructor in a rural area. I certainly agree that this skill is very easy to teach, this skill can be learned quite easily, AND since the indications and side effects are already known for use of an epi-pen by an EMT, this could be implemented with a savings of hundreds of dollars for the ambulance service, even the smallest rural service, who probably need the savings more than anyone else. BUT, as long as state laws require the epi-pen to be on the ambulance, there is nothing that can be done until the law changes. I don’t truly see why any first responder can’t be taught and allowed the ability to draw up the epi and inject it. It is truly a life saving measure in some cases. I’m in favor of epi-pens in schools, on soccer fields, and in the hands of those who are allergic with serious symptoms. Let’s get the skilled EMT the opportunity to provide the medication needed at a cost that is reasonable.

    • Barefoot in MN

      good points. Thank you !!…. I wonder, is the govt-imposed denial of the use of a vial & a needle due to the fear that the needles “might” be sold/stolen for use by drug addicts? a little like the situation with needles for diabetics? I know a piano technician who uses syringes to inject a very thin super-glue into small cracks in various piano repairs; (s)he has to get the syringes & needles from a veterinary supply house because the govt won’t allow a non-diabetic to simply buy them over-the-counter.

  • John Swanson

    I am currently in the State of Wisconsin in an EMT class. We DID learn how to draw up and inject Epi from vials. No great skill is required for drawing them up. Most BLS services in the area are rapidly dispensing with auto injectors just because of the rapid expiration date.