Epinephrine Roundtable

Last evening I sat on a roundtable discussion on the  the use of epinephrine in the backcountry at the 25th Anniversary and Annual Meeting of the Wilderness Medical Society.   

Dave Johnson MD from Wilderness Medical Associates was the initiative on this project.  The panel, moderated by Jay Lemery MD, included Dr Johnson, myself, Flavio Gaudio MD from Cornell, attorney Frances Mock, Carl Weil and Joanne Vitanza MD from Versus Pharmaceuticals (the Twinject people).

Highlights from the discussion include:

It’s difficult to know how common anaphylaxis is, both in the city, and the backcountry.  Definitions vary and hinder reporting.  The incidence of this rare, but deadly reaction is probably influenced by where and when program operates; some places have more bee and wasp stings, for example. 

Data collection has been a disappointment.  There have been several efforts over the years, but no compelling reason, other than AEE accreditation, for outdoor programs to submit data to a common database.  This epinephrine argument is a clear example of where diligence in data collection would be of value. 

In the absence of solid numbers our perceptions are influenced by the emotional hook of anaphylaxis.   Tales of patients with severe allergic responses saved with epinephrine circulate in the industry, yet documented accounts are elusive.     NOLS, for example, has only 2 incidents in the past 24 years where epinephrine was used for anaphylaxis (and no incidents where epinephrine was indicated and not administered).  The 1998-2005 WRMC data set, which includes 960,000 program days of back-country experience, has no incidents of anaphylaxis.  Dave Johnson, based on his experience, thinks these numbers are a low cohort.   I can’t disagree, the evidence does not allow us to draw conclusions about frequency.

We want to be prepared to treat this problem, yet worry that a layperson administering epinephrine to another person may not be supported by law.   Frances spoke to the legal dilemma of the law being behind the current medical standard of care.   Dave Johnson notes that the “horse is out of the barn” and the law will change to support layperson use of epinephrine, it may just take some time. 

There may be an expectation by parents and clients, driven by the attention to food allergies in the media, that the person in charge should be able to manage anaphylaxis, yet the legal support for epinephrine use by laypeople as a first aid skill, while improving, remains inconsistent state by state. 

A few states give Good Samaritan support to people administering epinephrine in an emergency.  Some states mandate training for camp counselors.  Some states have clear training requirements, others leave training to the equivalent of local medical control (e.g., physician, nurse practitioner).  Some states  include school bus drivers on the list for training, others do not allow EMT’s to initiate epinephrine treatment in the field (which of course, seems silly).

There are a number of advocacy groups supporting administration of epinephrine in anaphylaxis by well-trained first responders (school teachers, coaches, nurses, bus drivers, etc.).  These include the Food Allergy & Anaphylaxis Network and medical organizations such as  the American Academy of Allergy, Asthma and Immunology, American Academy of Pediatrics, the American Medical Association), the Red Cross and the American Heart Association in the 2005 First Aid Guidelines.  We hope our roundtable discussion leads to a similar statement of support by the Wilderness Medical Society for layperson use of epinephrine in the wilderness.