Emergency Epi Injection

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BulsangHanNamja

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Hi, as a pharmacist in a retail setting, is it okay to inject a patient with epipen that is having a true allergic reaction?
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BulsangHanNamja said:
Hi, as a pharmacist in a retail setting, is it okay to inject a patient with epipen that is having a true allergic reaction?
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Only if they have their own epi-pen or a valid rx for one at the pharmacy. Grabbing one off the shelf and stabbing someone randomly is illegal and a lawsuit waiting to happen if anything bad happens. Actually, it's still probably illegal to administer an epi-pen if they have an RX for one becasue administration of parenteral drugs are not our scope of practice (at least in NY) How do you know they are having a try allergic reaction, are you trained to diagnose? Come into the pharmacy in anaphlalyasis and I'll call you 911 and make you comfortable until the EMTs show up

I'm pretty sure we got into a huge pissing match about this a couple years ago on SDN. Edit: found the thread!
http://forums.studentdoctor.net/showthread.php?t=599360&highlight=epi-pen
 
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However, if this occurs as a result of a vaccination shot that the pharmacist gave the patient. There is a doctors protocol which a pharmacist must follow, which would probably include giving such a shot. Read the laws under vaccination for your state. There is a doctors protocol that should be followed.
 
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Should be good to do that here, you can pretty much do anything if it is first aid or to provide temporary assistance in the event of an emergency.

Of course, epinephrine in a self-administration device doesn't require an RX here.

Same with AEDs as they are applying electric current to the body.

Depends on your jurisdictions' laws.

I wish there was an intranasal/parenteral emergency Narcan program here, but naloxone is RX unfortunately.
 
BulsangHanNamja said:
Hi, as a pharmacist in a retail setting, is it okay to inject a patient with epipen that is having a true allergic reaction?
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No, see California Pharmacy Law with link and reference at this post:
http://forums.studentdoctor.net/threads/epi-pens-in-community-pharmacy.1047008/#post-16044909

Basically, the law still SADLY required WRITTEN ORDER from someone like physician and PHARMACY LABEL....(in emergency anaphylaxis, we don't have time for that.)

Some sentences of the law is here:
http://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml

4119.3.
(a) Notwithstanding any other law, a pharmacy may dispense epinephrine auto-injectors to a prehospital emergency medical care person or lay rescuer for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code, if both of the following requirements are met:
(1) A physician and surgeon provides a written order that specifies the quantity of epinephrine auto-injectors to be dispensed to a person described in subdivision (b) of Section 1797.197a of the Health and Safety Code. The physician and surgeon may issue the prescription only upon presentation of a current certificate demonstrating that the person is trained and qualified under Section 1797.197a of the Health and Safety Code to administer an epinephrine auto-injector to another person in an emergency situation. The prescription shall specify that the dispensed epinephrine auto-injector is for “First Aid Purposes Only” and that the named recipient is a “Section 1797.197a Responder.” A new prescription shall be written for any additional epinephrine auto-injectors required.
(2) (A) The pharmacy shall label each epinephrine auto-injector dispensed with all of the following:

I swore to Do No Harm BUT the law is still not supporting community pharmacist as EPIPEN injector in EMERGENCY situation yet....SAD....
 

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I would have just gave the mother an epi pen instead of letting her daughter die on a street.
 
molyhelp said:
No, see California Pharmacy Law with link and reference at this post:
http://forums.studentdoctor.net/threads/epi-pens-in-community-pharmacy.1047008/#post-16044909

Basically, the law still SADLY required WRITTEN ORDER from someone like physician and PHARMACY LABEL....(in emergency anaphylaxis, we don't have time for that.)

Some sentences of the law is here:
http://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml

4119.3.
(a) Notwithstanding any other law, a pharmacy may dispense epinephrine auto-injectors to a prehospital emergency medical care person or lay rescuer for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code, if both of the following requirements are met:
(1) A physician and surgeon provides a written order that specifies the quantity of epinephrine auto-injectors to be dispensed to a person described in subdivision (b) of Section 1797.197a of the Health and Safety Code. The physician and surgeon may issue the prescription only upon presentation of a current certificate demonstrating that the person is trained and qualified under Section 1797.197a of the Health and Safety Code to administer an epinephrine auto-injector to another person in an emergency situation. The prescription shall specify that the dispensed epinephrine auto-injector is for “First Aid Purposes Only” and that the named recipient is a “Section 1797.197a Responder.” A new prescription shall be written for any additional epinephrine auto-injectors required.
(2) (A) The pharmacy shall label each epinephrine auto-injector dispensed with all of the following:

I swore to Do No Harm BUT the law is still not supporting community pharmacist as EPIPEN injector in EMERGENCY situation yet....SAD....
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Why "sadly?"

There's nothing sad about this. If you inject someone with an epi pen, and he wasn't having an allergic reaction and ends up dying, YOU WILL GO TO PRISON.

If this situation ever presents itself, you immediately call 911. Protect yourself, your license and your career. We are drug experts, not paramedics. Pharmacists who try to be emergency response professionals piss me off to no end. If you think it's "sad" that we can't administer epi pen in an emergency, then leave the profession.

I'd rather NOT have to deal with the liability of these kinds of situations. I'd rather stick to dispensing and counseling, which is what I signed up for. If this ever happened to me, I'd call 911 immediately. By doing so, I would not get myself in trouble, would not get my employer in trouble, would not be acting out of practice and would be doing the patient what's best for them.
 
God this conversation again.

If someone is having an anaphylactic reaction I would just wait until they or their caregiver approached the counter and point at the Epi-Pens and state, "I can't give it to you, but I won't stop you".

If law enforcement ever questioned you, "I felt for the safety of myself and my employees, I wasn't going to be able to stop Person A from getting the EpiPen so I allowed them to steal it."

Easy game.
 
NateRobinson said:
Why "sadly?"

There's nothing sad about this. If you inject someone with an epi pen, and he wasn't having an allergic reaction and ends up dying, YOU WILL GO TO PRISON.
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No you won't. No jury would convict you.

You may be fired. And your employer may be sued. You may be sued in civil court. But you would never go to prison.
 
awval999 said:
No you won't. No jury would convict you.

You may be fired. And your employer may be sued. You may be sued in civil court. But you would never go to prison.
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What are you talking about? Do you mean to tell me if someone was having a NON ALLERGIC attack, and you for some reason thought an epipen would help, so you injected him with an epipen without a valid prescription from a doctor, thereby contributing to his death, that you wouldn't go to prison?

At the very LEAST, they would take your license away for practicing outside of scope.

What the poster above me said is GENIUS. You point to the epipens and say that's where they are, I'm not gonna stop you from getting them but I can't legally allow you access. Two birds with one stone.
 
NateRobinson said:
What are you talking about? Do you mean to tell me if someone was having a NON ALLERGIC attack, and you for some reason thought an epipen would help, so you injected him with an epipen without a valid prescription from a doctor, thereby contributing to his death, that you wouldn't go to prison?

At the very LEAST, they would take your license away for practicing outside of scope.

What the poster above me said is GENIUS. You point to the epipens and say that's where they are, I'm not gonna stop you from getting them but I can't legally allow you access. Two birds with one stone.
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That was me bro.
 
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NateRobinson said:
What are you talking about? Do you mean to tell me if someone was having a NON ALLERGIC attack, and you for some reason thought an epipen would help, so you injected him with an epipen without a valid prescription from a doctor, thereby contributing to his death, that you wouldn't go to prison?

At the very LEAST, they would take your license away for practicing outside of scope.

What the poster above me said is GENIUS. You point to the epipens and say that's where they are, I'm not gonna stop you from getting them but I can't legally allow you access. Two birds with one stone.
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What exactly do you mean by "non-allergic attack"? Any anaphylactoid reaction can be treated with epi... If they're having trouble breathing due to reactive airway disease, epi will ALWAYS help. Always. In every single case.
 
pharmnrp804 said:
What exactly do you mean by "non-allergic attack"? Any anaphylactoid reaction can be treated with epi... If they're having trouble breathing due to reactive airway disease, epi will ALWAYS help. Always. In every single case.
Click to expand...

I think they are referring to someone having a hypoglycemic reaction or some other non-airway involved "attack", that the pharmacist misdiagnosed as being an airway related "attack."
 
awval999 said:
No you won't. No jury would convict you.

You may be fired. And your employer may be sued. You may be sued in civil court. But you would never go to prison.
Click to expand...

It will be as if you went to prison. When the next of kin finds out from lawyers/media attention (headline, "pharmacist administers epi-pen injection that kills") that they can sue you (pharmacist) and employer (big dollar signs via settlement), they will come after you and your employer. Your employer may or may not throw you under the bus, but regardless, you will still hire your own lawyer for added protection. That isn't cheap. Will you roll the dice with a new grad that has no experience? Or will you pay the big bucks for the reputation of a winner (retainer: $10k/month)? It will be a long, drawn out process and you will wish that you never administered the injection. It took the courts 2 years to convict Ersland. Not apples to apples but that's a considerable amount of time. Put your life on pause and throw away the remote because the claimant has you by the balls.
 
pharmnrp804 said:
What exactly do you mean by "non-allergic attack"? Any anaphylactoid reaction can be treated with epi... If they're having trouble breathing due to reactive airway disease, epi will ALWAYS help. Always. In every single case.
Click to expand...

The differential for difficulty breathing is not limited to allergy and reactive airway disease. Lots of things can go wrong with lungs. Pneumothoraces, pulmonary embolism, MI, dissections, etc. may abruptly cause someone to have trouble breathing and may cause a lay person to think he's having an allergic response or an asthma attack.
 
eagles22 said:
The differential for difficulty breathing is not limited to allergy and reactive airway disease. Lots of things can go wrong with lungs. Pneumothoraces, pulmonary embolism, MI, dissections, etc. may abruptly cause someone to have trouble breathing and may cause a lay person to think he's having an allergic response or an asthma attack.
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Ah, yes. Lay people. I'd like to think that someone who has even a modicum of medical knowledge can tell the difference between an allergic reaction and any of those other pathologies. There is a very clear and obvious set of diagnostic criteria for each reactive airway disease, which anyone with experience dealing with these patients would know. The issue isn't lay people, it's healthcare providers.

BidingMyTime said:
I think they are referring to someone having a hypoglycemic reaction or some other non-airway involved "attack", that the pharmacist misdiagnosed as being an airway related "attack."
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So is this person just incompetent? In that case, they should get in trouble, but they should get in trouble the same way a physician, paramedic, nurse, PA, NP, or RT would for misdiagnosing. If you don't want that liability, then just like any of those other professionals, you have the choice to not deal with it. That being said, if I happened upon someone having an anaphylactoid reaction, I would want to do everything I could to help.
 
pharmnrp804 said:
Ah, yes. Lay people. I'd like to think that someone who has even a modicum of medical knowledge can tell the difference between an allergic reaction and any of those other pathologies. There is a very clear and obvious set of diagnostic criteria for each reactive airway disease, which anyone with experience dealing with these patients would know. The issue isn't lay people, it's healthcare providers.
Click to expand...

Say what? I was NOT trained in diagnosing, and NO, I would not feel comfortable diagnosing between any of those. Quite frankly, I highly doubt you or even a specialist doctor could diagnose between those just by looking at a patient for 5 seconds and not doing any sort of physical examination.


So is this person just incompetent? In that case, they should get in trouble, but they should get in trouble the same way a physician, paramedic, nurse, PA, NP, or RT would for misdiagnosing. If you don't want that liability, then just like any of those other professionals, you have the choice to not deal with it. That being said, if I happened upon someone having an anaphylactoid reaction, I would want to do everything I could to help.
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It is illegal for a nurse or RT to diagnose, and paramedic operate only under specific treatment protocols--they aren't "diagnosing" per se, rather they are stabilizing the patient until they can get to a medical practitioner who HAS been trained to examine & diagnose a patient.

My liability insurance does NOT include acting outside of my scope of practice, and that includes diagnoses of any sort. I also think you are greatly overestimating your abilities to diagnose a complete stranger.

Edited to add....I just realized you are a pharmacy student. I suspect you speak out of ignorance and as you go through pharmacy school your ideas on this subject may change.
 
BidingMyTime said:
Say what? I was NOT trained in diagnosing, and NO, I would not feel comfortable diagnosing between any of those. Quite frankly, I highly doubt you or even a specialist doctor could diagnose between those just by looking at a patient for 5 seconds and not doing any sort of physical examination.




It is illegal for a nurse or RT to diagnose, and paramedic operate only under specific treatment protocols--they aren't "diagnosing" per se, rather they are stabilizing the patient until they can get to a medical practitioner who HAS been trained to examine & diagnose a patient.

My liability insurance does NOT include acting outside of my scope of practice, and that includes diagnoses of any sort. I also think you are greatly overestimating your abilities to diagnose a complete stranger.

Edited to add....I just realized you are a pharmacy student. I suspect you speak out of ignorance and as you go through pharmacy school your ideas on this subject may change.
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Well I guess I'll work from the bottom up on this one... First of all, while I may be a pharmacy student, I've been a critical care paramedic for almost a decade. I've worked in urban and rural areas, as well as a level 1 trauma center, so I would say my experience is broad and varied when it comes to healthcare. Additionally, I've already been to graduate school, and I'm a faculty member at the institution where I'm obtaining my PharmD, so I'm not exactly your typical pharmacy student. That being said, I realize that my experience is limited, but I can only imagine that it's slightly different from yours.

As for YOUR ignorance of the job of a paramedic, we most certainly diagnose. It's not blindly following a treatment protocol, and it certainly isn't just stabilizing a patient until they get to a physician. We have extensive training in physical exam and differential diagnosis, and while it is certainly not on the level of a physician, it does allow me to tell the difference between a hypoglycemic episode and an asthma attack.

Lastly, like I said in my last post, if you don't want the liability, then don't do it. No one is forcing you. People have the choice to take on the responsibility that is comfortable for them, and that level of comfort won't be the same for everyone.
 
pharmnrp804 said:
Ah, yes. Lay people. I'd like to think that someone who has even a modicum of medical knowledge can tell the difference between an allergic reaction and any of those other pathologies. There is a very clear and obvious set of diagnostic criteria for each reactive airway disease, which anyone with experience dealing with these patients would know. The issue isn't lay people, it's healthcare providers.
Click to expand...

Without training in physical examination? Without listening to the lungs? How many community pharmacies have a stethoscope? How many community pharmacists have experience dealing with a or diagnosing a pneumothorax? Just because you know about something in theory or read about it for a class does not make one knowledgeable enough to treat. You need solid clinical training. Do you really want to stand in front of a jury saying "We, in my therepeutics class we talked about XYZ so I though I could treat it"?
 
Seems like we're talking about someone who walks through the door gasping for air between indicating that he has a peanut allergy for which he usually carries epic, and he just ate a peanut. Not rocket science...

I assume @pharmnrp804 is not talking about a person who just walks into the pharmacy and says he's short of breath.
 
BulsangHanNamja said:
Hi, as a pharmacist in a retail setting, is it okay to inject a patient with epipen that is having a true allergic reaction?
Click to expand...

If all you have in an emergency is a glass ampule of epi, and no filter, is it ok to administer IM unfiltered?
 
BidingMyTime said:
Filter needles on back-order like 30% of other common pharmacy items?
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And you don't have epi-pens or auvi-q's available?

In a matter of life or death, you could draw it up through sterile cotton (search heroin user message boards for more details).
 
BidingMyTime said:
Filter needles on back-order like 30% of other common pharmacy items?
Click to expand...

In a world where D5W, NS, and sterile water have all been on backorder in the past year.. hell, why not?

Sometimes I swear that "Refrigerate" stickers are on back order, but maybe that's just me.
 
My rough estimate, at any given time, across all practice settings, 20% of pharmaceutical products are back-ordered/allocated/short-supplied.
 
BidingMyTime said:
My rough estimate, at any given time, across all practice settings, 20% of pharmaceutical products are back-ordered/allocated/short-supplied.
Click to expand...
I don't think you're taking into account the junk nobody wants. That estimate is way too high.
 
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