Hypothetical emergency situation....

[NormalSaline]

You are working in a busy retail store. A ~30 yr old man rushes up to the counter and shoves his way to the front. Through all sorts of wheezing/ 2 word sentences/ struggling, he manages to explain to you that he has asthma and has misplaced his rescue inhaler.

You can clearly see his SOB, use of accessory muscles to breathe etc etc. He has never filled at your store so you can't check his profile to see what he has had in the past.

Obviously you call an ambulance, which wont be there for at least 10 minutes. In the meanwhile, do you grab an albuterol MDI off the shelf and give it to him?

Does the age of the patient change your decision process? What if he is 2 years old and his mom brings him to you? What if he is a crotchety 85 year old with COPD?

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[Phlame217]

Had this actually happen with a similar scenario,

My pharmacy is located near a restaurant strip and we had a lady bust through our typical crowd clamoring for us to give her an epipen as her husband was having and allergic reaction to shell fish. As our world is, My pharmacist had encountered a previous situation to this, and he said to call emergency services and also asked to know what pharmacy he typically filled at and we would meanwhile aquire verification of a previous epipen script.
In the end, the emergency ambulance arrived and gave him a shot of adrenaline and he was on his way.

Reason for the pharmacists decision, a similar case much earlier in is career had occured and he did the obvious and handed over a epipen and long story short, the patient suffered some injuries as he was not having a anaphalactic reaction, but was a diabetic and in a hyperglycemic shock and the pharmacist ended up getting sued and lost.

so to answer your question, I would call emergency services and offer to contact the persons doctor/pharmacy and obtain information to appropriate choose medicines.

 

[PumpkinSmasher]

You are working in a busy retail store. A ~30 yr old man rushes up to the counter and shoves his way to the front. Through all sorts of wheezing/ 2 word sentences/ struggling, he manages to explain to you that he has asthma and has misplaced his rescue inhaler.

You can clearly see his SOB, use of accessory muscles to breathe etc etc. He has never filled at your store so you can't check his profile to see what he has had in the past.

Obviously you call an ambulance, which wont be there for at least 10 minutes. In the meanwhile, do you grab an albuterol MDI off the shelf and give it to him?

Does the age of the patient change your decision process? What if he is 2 years old and his mom brings him to you? What if he is a crotchety 85 year old with COPD?

I hate people who cut in line.

 

[Sparda29]

This is assuming that the patient is knowledgeable and knows what medication they have been taking.

First, have a tech call-up emergency services.

Second, bring a pen and a paper to the patient to write down the phone number of the pharmacy they usually use. Call em up, find out what they usually take for asthma, dispense.

If none of that is possible, I'd bring up any of the possible rescue inhalers and ask the patient to choose which one he uses (flaw here is that if the patient is delirious, might choose incorrect one, or if the patient doesn't know what they take(usually the case).

BTW, to anyone else who works in a pharmacy, do you guys have an AED on site?

 

[PumpkinSmasher]

This is assuming that the patient is knowledgeable and knows what medication they have been taking.

First, have a tech call-up emergency services.

Second, bring a pen and a paper to the patient to write down the phone number of the pharmacy they usually use. Call em up, find out what they usually take for asthma, dispense.

If none of that is possible, I'd bring up any of the possible rescue inhalers and ask the patient to choose which one he uses (flaw here is that if the patient is delirious, might choose incorrect one, or if the patient doesn't know what they take(usually the case).

BTW, to anyone else who works in a pharmacy, do you guys have an AED on site?

The store has one somewhere. Probably in the bathroom or janitor's closet.

 

[npage148]

I'll call 911, but I'm not going to give him an inhaler. I'm not an emergency medicine doctor and I'm not taking that chance. If the inhaler for some reason hurts him you know the family is coming after you. I'm sorry but why did you run to a pharmacy when you could have just as easily gone to the ER instead. Where I'm from, there are 3 ER's within 10 minutes of my pharmacy

 

[Vitamin K]

If it's definitely asthma and he can't breathe (as the OP suggests), then yes, I would. That should be a no-brainer. My pharmacy manager was put in this exact situation, and he did the same thing that I would. Patient first. If I had any reason to believe that it wasn't a severe asthma attack, I wouldn't.

 

[Aznfarmerboi]

I live in NYC. Call 911. Unless the person requires first aid ie CPR, you shouldnt be helping them. Of course the situation may differ in another state or rural setting.

 

[RxWildcat]

Call 911 and give him primatene mist OTC. Problem solved.

 

[Sparda29]

Call 911 and give him primatene mist OTC. Problem solved.

Of course, the cartons of Primatene Mist OTC are nowhere to be found at my store.

 

[Old Timer]

Call 911 and give him primatene mist OTC. Problem solved.

If you are going to give him Primatene, you might as well give Albuterol. It's safer. It's being willing to make the diagnosis that will get you in trouble, not just the therapy you selected....

 

[UBCmicrobi]

BTW, to anyone else who works in a pharmacy, do you guys have an AED on site?

We've got an AED, but as far as I know only my manager is trained to use it (and obviously she isn't there all the time), but apparently they are pretty easy to use, although I don't know how comfortable I would be using it without proper training.

 

[NormalSaline]

We've got an AED, but as far as I know only my manager is trained to use it (and obviously she isn't there all the time), but apparently they are pretty easy to use, although I don't know how comfortable I would be using it without proper training.

I think you'd be shocked by how easy it is.

It pays to keep your AED knowledge current.

When it comes to using those things, you can never miss a beat

After reading up on AED's, I'd feel right at ohm using one

 

[PumpkinSmasher]

I think you'd be shocked by how easy it is.

It pays to keep your AED knowledge current.

When it comes to using those things, you can never miss a beat

After reading up on AED's, I'd feel right at ohm using one

You nerd...

 

[Omegadramon]

^Puns!

 

[UBCmicrobi]

I think you'd be shocked by how easy it is.

It pays to keep your AED knowledge current.

When it comes to using those things, you can never miss a beat

After reading up on AED's, I'd feel right at ohm using one

I'm not required to be trained to use one as far as work is concerned (liability issues in the work place), and unfortunately the first aid course I did recently for school didn't include AED training. In our mock emergencies we just had to say "you, go find me an AED and a person who is trained to use an AED". lol

We are now selling AEDs for home use, too.

 

[pinkyrx]

I'm not required to be trained to use one as far as work is concerned (liability issues in the work place), and unfortunately the first aid course I did recently for school didn't include AED training. In our mock emergencies we just had to say "you, go find me an AED and a person who is trained to use an AED". lol

We are now selling AEDs for home use, too.

AEDs are super easy to use... The toughest part is remembering to turn the power on.

 

[RxWildcat]

I think you'd be shocked by how easy it is.

It pays to keep your AED knowledge current.

When it comes to using those things, you can never miss a beat

After reading up on AED's, I'd feel right at ohm using one

I love it!

 

[rxforlife2004]

We've got an AED, but as far as I know only my manager is trained to use it (and obviously she isn't there all the time), but apparently they are pretty easy to use, although I don't know how comfortable I would be using it without proper training.

You don't just AED anyone...yet in this case, it is a poor choice. Sure, have it ready, but i doubt you would use it unless pt starts collapsing ,unconcious or having cardiac arrest/ ACS symtoms....then you follow ACLS algorithm.

Back to the story, if pt is alert, awake, concious...ask him "Do you have history of asthma?" If yes, then definitely get him a Ventolin HFA STAT. If he shakes his head, then it's your judgement call and stick with ur decision. Now if the pt starts to have cardiac arrest, then you better know your ACLS...what to do next. If you don't, then at least perform CPR, and call 911 (this calling 911 should be done from the very beginning ).

 

[UBCmicrobi]

You don't just AED anyone...yet in this case, it is a poor choice. Sure, have it ready, but i doubt you would use it unless pt starts collapsing ,unconcious or having cardiac arrest/ ACS symtoms....then you follow ACLS algorithm.

No I wouldn't "just AED anyone", the AED was not a suggested treatment for the asthmatic patient in the above scenario! we were just talking about AEDs as an aside lol

 

[AngelaCL]

I would log on to SDN and ask everyone what to do.

 

[cycloketocaine]

If none of that is possible, I'd bring up any of the possible rescue inhalers and ask the patient to choose which one he uses (flaw here is that if the patient is delirious, might choose incorrect one, or if the patient doesn't know what they take(usually the case).

I hope you have great malpractice insurance.

 

[acetyl]

If you are going to give him Primatene, you might as well give Albuterol. It's safer. It's being willing to make the diagnosis that will get you in trouble, not just the therapy you selected....

How is recommending an OTC drug and giving a legend drug without a RX the same? I don't see how telling someone sort of breath to use a Primatene inhaler is the same as giving a stranger a RX drug.

If albuterol is so much safer than Epi, then why isn't it OTC as well?

 

[meister]

I'd do a quick physical exam and prescribe him a single albuterol MDI. The stuff's pretty harmless guys, some of you people are just mean!

And not giving an epipen when asked? Yikes, that is just terrible. Take the patient's drivers license and insurance card, get his physician's phone number, verify history of whatever the allergy is, and hand it over. Yeah, you might technically be breaking the law, but hey, you might save someone's life. How often do you get to do that?

There is a reason there is such a thing as professional discretion, I'd say more of you should utilize it.

 

[All4MyDaughter]

It's all good until your well-intentioned action results in a less-than-optimal outcome. Then, you would be on the hook for practicing medicine without a license. Good Samaritan laws don't apply if you exceed what you are trained to do. I don't know that Walgreens/CVS/Rite Aid/Kroger, etc would back up a pharmacist who harmed someone in a situation like this. Of course, if the intervention doesn't result in harm to the patient you probably are in the clear... is it a gamble that we should take with our licenses/livelihood?

I live in a large city where ambulance help is never more than a few minutes away.

I have seen patients come in and ask for Epipens who were clearly NOT in anaphylaxis...

 

[HaleyRX]

it is sad that people are so sue-happy these days that this becomes an issue. it seems like common sense that if you have something that could help someone you should give it to them---but really it isn't common sense at all. it is a lawsuit waiting to happen.
with that said, how many of you would do "emergency fills" that might/might not be emergency exactly --i.e, patient is from another town, doesn't use your pharmacy, needs a week of Lexapro? or a patient's dr. is out of town and they need birth control but don't have refills left? do you fill it?
I mean these are important but not life or death...
I'm just curious.

 

[cycloketocaine]

it is sad that people are so sue-happy these days that this becomes an issue. it seems like common sense that if you have something that could help someone you should give it to them---but really it isn't common sense at all. it is a lawsuit waiting to happen.
with that said, how many of you would do "emergency fills" that might/might not be emergency exactly --i.e, patient is from another town, doesn't use your pharmacy, needs a week of Lexapro? or a patient's dr. is out of town and they need birth control but don't have refills left? do you fill it?
I mean these are important but not life or death...
I'm just curious.

There is no way that I would fill someones Lexapro who is "from another town" without a valid prescription. And, women usually know when their BC is out of refills and its time for a check up, and if they wait till they are out and their doctor is out of town, that's tough chit.

 

[meister]

I have seen pharmacists hand out 1 or 2 pills off the books lots of times, how many of you don't do this for BP or diabetes medicine? Really?

I don't know, if someone has epipens at home, forgot them, and their kid got stung by a bee in the parking lot, you really wouldn't give it to them?

 

[Sparda29]

There is no way that I would fill someones Lexapro who is "from another town" without a valid prescription. And, women usually know when their BC is out of refills and its time for a check up, and if they wait till they are out and their doctor is out of town, that's tough chit.

BC, we're pretty tough with. If you're out of refills and want to have sex, better buy a condom.

 

[UBCmicrobi]

bc, we're pretty tough with. If you're out of refills and want to have sex, better buy a condom.

yes!!!

 

[StallionRx]

It's all good until your well-intentioned action results in a less-than-optimal outcome. Then, you would be on the hook for practicing medicine without a license. Good Samaritan laws don't apply if you exceed what you are trained to do. I don't know that Walgreens/CVS/Rite Aid/Kroger, etc would back up a pharmacist who harmed someone in a situation like this. Of course, if the intervention doesn't result in harm to the patient you probably are in the clear... is it a gamble that we should take with our licenses/livelihood?

I live in a large city where ambulance help is never more than a few minutes away.

I have seen patients come in and ask for Epipens who were clearly NOT in anaphylaxis...

I agree.

Its not about being mean, its about protecting yourself AND the person in need of help. Im not a doctor and I dont pretend to be one.

I had a woman collapse last week in the pharmacy and go unconscience for about 30 seconds. My intern insisted on giving her some oral glucose. I called 911 to get the EMTs there and asked if they thought it was a good idea to treat her. 911 said absolutely DO NOT GIVE HER ANYTHING.

Good thread.

 

[npage148]

I have seen pharmacists hand out 1 or 2 pills off the books lots of times, how many of you don't do this for BP or diabetes medicine? Really?

I don't know, if someone has epipens at home, forgot them, and their kid got stung by a bee in the parking lot, you really wouldn't give it to them?

The whole thing with the first hypothetical situation was that the person was NEVER a customer at our pharmacy. No way to verify in the profile or anything. It would be completely different if the customer came to use regularly. But no, if I never saw the kid before I'm not giving them an epi pen. I know it sucks for them but as someone else mentioned everyone is so sue happy these days.

 

[aboveliquidice]

I'm not required to be trained to use one as far as work is concerned (liability issues in the work place), and unfortunately the first aid course I did recently for school didn't include AED training. In our mock emergencies we just had to say "you, go find me an AED and a person who is trained to use an AED". lol

We are now selling AEDs for home use, too.

Really... We had to do BCLS... as first years. ACLS as second years The course was paid for of course - tacked on to our redunculous student fees

~above~

 

[meister]

Heh that's interesting, they don't require us to do any BCLS training as of yet, I'm halfway through M1. I don't think they will, it's probably all on the job during M3.

npage148: So if someone's 3 year old was clearly stung by a bee in the parking lot, the mom comes back frantic and says she's forget her epipen at home, the kid is not breathing and clearly in shock, you would deny them? I just don't see how someone could do that, litigous society or not. I mean I don't have a pharmacy license to protect, but it seems like a pretty easily defendable situation to me...

There aren't many pathologies a 3 year old could have that an epipen would worsen.

 

[MountainPharmD]

I have seen pharmacists hand out 1 or 2 pills off the books lots of times, how many of you don't do this for BP or diabetes medicine? Really?

I don't know, if someone has epipens at home, forgot them, and their kid got stung by a bee in the parking lot, you really wouldn't give it to them?

I have said this to many a student. It’s easy to be an armchair quarterback as a tech, a student or an intern. Once you put on the white coat as the pharmacist the whole thing changes. When your job pays the mortgage and buys food for the kids there are not many gray areas. You follow the letter of the law. You stick your neck out too many times it will get cut off.

As far as you comment on loaner pills. It depends on the state. Texas specifically allows this in its pharmacy rules and regulations. We are allowed to fill a three day supply of medication on a prescription that has recently run out of refills or expired. We have to make a good faith effort to contact the doctor before loaning the pills.

 

[npage148]

npage148: So if someone's 3 year old was clearly stung by a bee in the parking lot, the mom comes back frantic and says she's forget her epipen at home, the kid is not breathing and clearly in shock, you would deny them? I just don't see how someone could do that, litigous society or not. I mean I don't have a pharmacy license to protect, but it seems like a pretty easily defendable situation to me...

There aren't many pathologies a 3 year old could have that an epipen would worsen.

Sure there are not many, but what if the kid dies and it shows for some whack reason that the epi had a contributory factor. I'm screwed for life regardless of anything. There are other reasons too since we are talking hypothetically. What if the mom only thought he got stung, what if he's choking on something. What if he's not in anaphylaxis but some cardiac arrhythmia. You are going to give a potentially deadly medicine based on a stressed mom's recall. I'm not trained to assess the situation and administer treatment.

But I can't say 100% because I've never been in that situation but you'd be hard pressed to get me to do it

 

[confettiflyer]

Sure there are not many, but what if the kid dies and it shows for some whack reason that the epi had a contributory factor. I'm screwed for life regardless of anything. There are other reasons too since we are talking hypothetically. What if the mom only thought he got stung, what if he's choking on something. What if he's not in anaphylaxis but some cardiac arrhythmia. You are going to give a potentially deadly medicine based on a stressed mom's recall. I'm not trained to assess the situation and administer treatment.

bingo, you hit it on the head. even if this same woman came screaming into the ED with this same situation, the MD will still assess and THEN make the decision. Pharmacists aren't trained at diagnosis the way physicians are, period.

However, if you DO have the training/knowledge...it is your license, be my guest. Someone mentioned it above, but good samaritan laws protect health care providers who act within the scope of their responsibilities. Dispensing medicine, however innocuous it may seem, without an appropriate examination by a qualified health care professional is practicing out of scope and thus not covered.

Despite the appearance of a person in a white coat, clinics and hospitals are two very different places for two entirely different things.

In the end, it's situational...if that same screaming mother came in with a bee still attached to the kid's arm and a broken epipen in the other and that kid is swelling up like a hot air balloon...I'd step out of the box and provide the pen.

 

[npage148]

Then again, I've always wanted to stab someone with an EpiPen so maybe I'll take my chances

 

[lesphoques]

^agreed.

I say do whatever the hell you want in ANY situation as long as you can justify it yourself and are comfortable with the consequences.

 

[confettiflyer]

^agreed.

I say do whatever the hell you want in ANY situation as long as you can justify it yourself and are comfortable with the consequences.

Unfortunately these days, this won't stand in court (if your case even gets that far). I mean, I can justify a whole mess of things...doesn't make it legal/ethical/moral/etc...

 

[UBCmicrobi]

Someone mentioned it above, but good samaritan laws protect health care providers who act within the scope of their responsibilities.

Exactly.

It would definitely be a different situation if you were not in the workplace/healthcare setting. If you're in the park, kid gets stung by a bee, mom frantically searches through her purse but can't find the epipen and yells out "does anyone have an epipen", and you just so happen to have one in your bag...here good samaritan laws might protect you.

 

[acetyl]

Loaning a few metformin or atenolol to a chronic med patient at your pharmacy whom you've filled prescriptions for over the last few years....and giving the crazy, frantic, stranger patient who has self-diagnosed a medical condition a RX drug is not even in the same ball park.

 

[UBCmicrobi]

Loaning a few metformin or atenolol to a chronic med patient at your pharmacy whom you've filled prescriptions for over the last few years....and giving the crazy, frantic, stranger patient who has self-diagnosed a medical condition a RX drug is not even in the same ball park.

of course I know that one should not give Rx medication to those for whom it was not prescribed, but my point was that as a private citizen, you would likely be protected by good samaritan laws, but INSIDE the pharmacy you would be bound to practising within your scope and therefore are NOT protected by good samaritan laws if you step outside your scope.

I didn't comment on emergency supplies of chronic meds, that is of course a whole 'nother story, and may be well within the laws governing your state (or in my case province). There's a few too many hypothetical situations floating around here, I think people are getting confused....just as I wouldn't AED some one with SOB.


Edit, sorry I can't tell if that was in response to my comment or not.....apologies if it wasn't, but always good to clarify.

 

[Aznfarmerboi]

Agreed. Like other pharmacists said, do not give. I would not even give the Epipen if I was at a park and somebody else needs it. That alone violates federal law where a prescription drug should not be transferred from a person other than whom it was intended for.

Like WVU said, after a while on the job, you realize that there are so many things that can get you into trouble. Every few weeks or so, we'll have a pharmacist get in trouble, sue, and even one on the run for things we would have never imagined.

Good samaritan laws protect healthcare workers and require first responder and healthcare workers to help a person in need based on their training. That means we have to give CPR and identify ourselves as pharmacists when somebody needs help. However helping a stranger requires diagnosising. Of course if the script is already in your records, the patient is diagnosised and I think is okay to give in many cases.

Another scenario is somebody experiencing a seizure. As a first responder and health care professional, you should clear the things around the person if possible. If you dont. . . you might get sued.

The key here is that in court, they will ask you when did you recieve the training? What are the exact procedures? Are you up to date with your training? etc.

 

[Kittenmommy]

You are working in a busy retail store. A ~30 yr old man rushes up to the counter and shoves his way to the front. Through all sorts of wheezing/ 2 word sentences/ struggling, he manages to explain to you that he has asthma and has misplaced his rescue inhaler.

You can clearly see his SOB, use of accessory muscles to breathe etc etc. He has never filled at your store so you can't check his profile to see what he has had in the past.

Obviously you call an ambulance, which wont be there for at least 10 minutes. In the meanwhile, do you grab an albuterol MDI off the shelf and give it to him?

This actually happened to Kittendaddy.

We were out somewhere and he realized he didn't have his inhaler. As often happens when an asthmatic person doesn't have access to his/her inhaler, the anxiety about having an attack triggered an attack.

We saw a CVS and I told him to pull over (he was driving, OMG), and while he parked, I ran inside, ran to the pharmacy counter, and explained that my husband was having an asthma attack and needed an Albuterol inhaler. They gave me one, no questions asked. When he arrived a moment later, he used the inhaler and everything was fine.

We asked if they would sell him the inhaler (since obviously they couldn't dispense it to anyone else after he'd used it) and they looked in their computer and saw that he used to have a prescription for it that was called in by my uncle when we first moved down here and Kittendaddy didn't yet have a local doctor. So they sold us the inhaler, and we all lived happily ever after all was well.

tl;dr: They gave me an inhaler with no problem when I said my husband was having an asthma attack.

 

[tjaze]

This actually happened to Kittendaddy.

We were out somewhere and he realized he didn't have his inhaler. As often happens when an asthmatic person doesn't have access to his/her inhaler, the anxiety about having an attack triggered an attack.

We saw a CVS and I told him to pull over (he was driving, OMG), and while he parked, I ran inside, ran to the pharmacy counter, and explained that my husband was having an asthma attack and needed an Albuterol inhaler. They gave me one, no questions asked. When he arrived a moment later, he used the inhaler and everything was fine.

We asked if they would sell him the inhaler (since obviously they couldn't dispense it to anyone else after he'd used it) and they looked in their computer and saw that he used to have a prescription for it that was called in by my uncle when we first moved down here and Kittendaddy didn't yet have a local doctor. So they sold us the inhaler, and we all lived happily ever after all was well.

tl;dr: They gave me an inhaler with no problem when I said my husband was having an asthma attack.

that was nice of them. unfortunately, i personally wouldn't have. stupid media has made people think they know everything cause they heard it on tv. and when they're wrong, you'll be blamed. med students are pretty much taught to cover yourself in case of lawsuit with every patient. not to mention how obama and cnn are painting doctors as greedy soulless people. makes me think first about keeping my license before saving someone's life. it's simply sad.

 

[Thoughtfulsinner]

Let them die and save your license. Sounds good to me chicken littles.

 

[Pharmavixen]

I couldn't get an inhaler out of a pharmacy in a small town in southern Ontario when I suffered an asthma exacerbation from trying to ride a bicycle from Toronto to Niagara Falls. My dr hides behind voicemail, so I called the jail, and the dr there cheerfully phoned in a script for me.

 

[lorain]

nope not me sorry....if you aint in my system and what not, i aint giving you anything....i'll call 911 for you thou....im not a ER doctor and there are 4 ERs near me, including a level 1 trauma center....so why would you come to a damn retail pharm and not got to the other 4 institutions?

 

[StringTheorist]

Are you guys serious? If a guy is generally at risk of not getting enough oxygen and the only thing standing in between consciousness and unconsciousness/death is a freaking albuterol inhaler, I'd pull one off the shelf. Same thing for an epi pen. I would then call his PCP, explain the seriousness of the situation, how he appeared, my train of thought, and what I did, and get a retroactive Rx. No patient of mine is dying under my watch if something can be done about it and it is common sense. I would consider it neglect if I DIDN'T do anything about it.