The pharmacist's role in emergency situations

[crossurfingers]

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I witnessed a car accident today involving an elderly woman and another family that rear ended her. She walked herself over to the curb and then all of a sudden started crawling on the ground by the grass. There were no visible signs of injury- from the looks of it just whiplash but she was hyperventilating and crying. There was a nurse that stopped and helped her. With all this schooling in the medical field I feel like I should be able to do more than just ask her what medications she's on and if she had any other health conditions. 🙁

What other things do you think pharmacists can do in emergency situations like this?

 

[DrMom]

Call 911

 

[emtp2pac]

go mix some amiodarone for me while I intubate and start the iv....
all kidding aside, we have pharmd's respond to every code to help facilitate acquiring needed meds and on occassion doing a few calculations in selected patient populations( small kids, renal failure, etc) so there is a role for a pharmd on an in-hospital code team. if you want to be of more help outside the hospital take an advanced first aid, first responder or emt course and carry a good first aid kit in your car..

 

[imperial frog]

Don't feel to bad. For most people in the medical field, emergency training just isn't their bag and how you need to respond in an emergency is probably totally different then how you respond during your normal work.

I used to work in an ER and I found that non-ER nurses and doctors didn't have a clue what to do when a gunshot or car crash came in because the type of care that was needed was different then what they were trained to do. They were used to treating a stabalized person, not getting them stabalized. I responded to one crash while doing EMT training and a doctor tried to take over the situation. When asked if he ever had emergency experience he said no and was ignored from then on.

On the other hand, put an ER nurse on a floor, and he/she is going to be out of their element too.

Keep in mind that unless you know what you are doing, you can make the situation worse. The best thing to do is call 911, make sure they are breathing, and stop them from moving around. And don't feel bad if you can't do more.

 

[emtp2pac]

controlling major bleeding with direct pressure is probably a good no brainer too......

 

[imperial frog]

That too.

 

[indoflip]

keep up with the CPR certification 👍

 

[baggywrinkle]

keep up with the CPR certification 👍

Don't forget your ABC's

The the challenge comes when something happens in your pharmacy and you
are faced with taking care of your ailing customer or covering your butt.

Case in point; a woman came into my pharmacy with an impending allergic
reaction to shellfish. She was barely able to make it to the waiting area chairs
with assistance. Paramedics arrived before she really went south, but the thought crossed my mind that benadryl and an epi-pen were only 15 feet away. What would YOU have done had she stopped breathing? Keep counting and pouring? Do basic life support? Or jump over the counter and administer the epi-pen thus breaking the law?

 

[kwakster928]

Don't forget your ABC's

The the challenge comes when something happens in your pharmacy and you
are faced with taking care of your ailing customer or covering your butt.

Case in point; a woman came into my pharmacy with an impending allergic
reaction to shellfish. She was barely able to make it to the waiting area chairs
with assistance. Paramedics arrived before she really went south, but the thought crossed my mind that benadryl and an epi-pen were only 15 feet away. What would YOU have done had she stopped breathing? Keep counting and pouring? Do basic life support? Or jump over the counter and administer the epi-pen thus breaking the law?

I would use epi-pen. but i will be crapping my pants afterwards.

 

[bananaface]

It's pretty hard to practice pharmacy without breaking the law at some point. What we are willing to break the law for says alot about who we are. Saving a life is a pretty good justification, in my book. Many pharmacists will do it for convenience's sake, like dispensing a birth control refill as a "fill and gone". The same law is being broken in this and the Epi-Pen scenario. It's sad how the more urgent of the two situations is the one in which fewer of us would be willing to dispense. If you are going to break the law, ideally it would be for a case in which you would be willing to publicly acknowledge and justify your actions.

Now, I'm not saying that administering the Epi-Pen without a prescription is the right thing to do in the situation. The right thing to do is to stop being scared of getting slapped on the wrists and think about how you can get the patient what they need. What you could do, while your technician dials 911, is to dial your local ED, state who you are, and ask to speak to the physician on duty. Seeing as how the patient will be shipped to them shortly anyway, they should give you a quick verbal over the phone.

Don Williams, the recently retired executive director of the Washington State Board of Pharmacy made an interesting point while lecturing in my pharmacy law class last week. He said when it comes to issues of law that are questionable, physicians routinely risk breaking the law and ask for forgiveness afterwards. Pharmacists incessantly call and ask permission of the board before doing things, even when doing so is clearly not in the best interests of the patient.

 

[baggywrinkle]

Now, I'm not saying that administering the Epi-Pen without a prescription is the right thing to do in the situation. The right thing to do is to stop being scared of getting slapped on the wrists and think about how you can get the patient what they need. What you could do, while your technician dials 911, is to dial your local ED, state who you are, and ask to speak to the physician on duty. Seeing as how the patient will be shipped to them shortly anyway, they should give you a quick verbal over the phone.

.

Been there done that. Unless you drink coffee with that ER doc don't waste
your time. The ER will not touch it without seeing him. I had a guy wander in with chest pain asking for nitroglycerin. He had never filled with me or it would have been a non issue. All I got from the ER was stonewalled.

The fellow left my store with ntg 0.4mg and a stern warning to follow up.

These scenarios happen frequently folks. A kid last night with an infection
in his tear duct came to me for help. His friends had sent him to the local feed store for livestock antibiotics. The warnings had frightened him and he came to me. I broke his heart and told him he needed to see a doctor. What would you have done? What would you have done if it was your best friend?

 

[Ivorymist]

I had a rotation in the ER at a huge urban teaching hospital, and the pharmacist I followed around played doctor on several occasions. He would read EKGs, administer meds, etc. Really makes you wonder where to draw the line. He's obviously highly educated, but it's not what you would imagine a pharmacist doing.

As for the retail scenario, unless it's for an epipen or possibly an emergency puff of albuterol (even that's doubtful), I don't think I'll ever be gutsy enough to dispense anything without an Rx. This opens up lots of moral dilemmas, and that's one reason why I don't want to end up in retail...there are times when you know exactly what to do, only to have no authority to do it.

 

[Lexian]

I agree with pretty much all of the posts so far. Emergency situations require not only training, but most importantly, experience. A pharmacist would really be out of his/her element responding to an accident or emergency situation that would occur, but that would go for anyone who is not a trained EMT or ER regular.

I think the best advice to give is that if you see an accident to treat it like any passerby or regular civilian should. Survey and assess the safety of the scene, ask if the victim is alright and if you can help them (if they are conscious, of course), and call 911 or ask someone to call 911 for you while you attend to the victim. This is something that everyone can do, whether they are a health professional or not. CPR training, knowing your ABC's, and having first aid training is also a plus.

 

[Lone Kendoka]

I never thought of this kind of thing before, but thinking about it now, I know that I want to be able to help people in any and every way I can. I hate feeling that sense of helplessness when I see someone needing medical assistance, but not knowing how to help or knowing how to help, but am restricted from acting on it because it goes against the law.

 

[tungsten87]

 

[apteryx]

I lol'd hard.

Oh yeah, Mr. Saturn kicks ass.

 

[Sparda29]

CPR/AED, First Aid, checking vital signs, and relocating a dislocated shoulder.

Other than that, do it at your own risk.

 

[tungsten87]

I lol'd hard.

Oh yeah, Mr. Saturn kicks ass.

have you played through earthbound?

 

[WVUPharm2007]

This always cracks me up. People sometimes come up with this hypothetical situation on an airplane where a dude has a heart attack..."oh, if only there was a doctor." WTF is the physician going to do? Tell us about what he'd do if he was in an actual hospital with tools and drugs?

Unless you are some sort of weirdo that carries TPA and and ECG machine with you at all times, the only thing you can do is call in the EMTs...with their fancy drugs and gizmos...

 

[konkan]

I witnessed a car accident today involving an elderly woman and another family that rear ended her. She walked herself over to the curb and then all of a sudden started crawling on the ground by the grass. There were no visible signs of injury- from the looks of it just whiplash but she was hyperventilating and crying. There was a nurse that stopped and helped her. With all this schooling in the medical field I feel like I should be able to do more than just ask her what medications she's on and if she had any other health conditions. 🙁

What other things do you think pharmacists can do in emergency situations like this?

Tap on the shoulder and ask: "Is everything ok?"

 

[Old Timer]

If you give an Epi-pen w/o an order, you have committed a crime at worst, or violated your state's regulations at worse. Since you are a health professional and not a "Good Samaritan" your insurance would not cover this either if the patient went south and died.

As a pharmacist, you have certain training and you have to know when it's OK to do something and when you have let somebody else do it. This would be one of those times to bow out...

 

[apteryx]

have you played through earthbound?

One of my top 10 favorite games. Mother 3 was even better. Different, but I liked it.

 

[njac]

I took a Wilderness Medicine elective during residency that addressed a lot of the medico/legal stuff.

I would do whatever was necessary.

Pressure to stop bleeding, CPR, stay with the patient and wait for help, make the patient wait in the car, etc etc etc.

I can also make traction with an umbrella and a tshirt 😉

 

[Sparda29]

I took a Wilderness Medicine elective during residency that addressed a lot of the medico/legal stuff.

I would do whatever was necessary.

Pressure to stop bleeding, CPR, stay with the patient and wait for help, make the patient wait in the car, etc etc etc.

I can also make traction with an umbrella and a tshirt 😉

I don't know about waiting in the car. I guess it depends on what the car's status is. If it's leaking gasoline or is smoking, I don't care if I break a vertebrae in the process, I'm gonna pull the person out of there.

 

[awval999]

If you give an Epi-pen w/o an order, you have committed a crime at worst, or violated your state's regulations at worse. Since you are a health professional and not a "Good Samaritan" your insurance would not cover this either if the patient went south and died.

As a pharmacist, you have certain training and you have to know when it's OK to do something and when you have let somebody else do it. This would be one of those times to bow out...

Oh please. Acting in the best interest of the patient is all that matters. No jury will convict you for giving an Epi-Pen to a guy holding his throat, gasping for breath and with rash all over his body with a wife crying and saying that he got stung by a bee. Hell what are you going to do when the wife jumps over the counter and takes one? Hold her down?

 

[AbbyNormal]

Why not give the epi pen to the man and let him self administer?

Yeah I get that it still violates the law dispensing without a Rx but wouldn't that be better than administering it?

 

[Old Timer]

Oh please. Acting in the best interest of the patient is all that matters. No jury will convict you for giving an Epi-Pen to a guy holding his throat, gasping for breath and with rash all over his body with a wife crying and saying that he got stung by a bee. Hell what are you going to do when the wife jumps over the counter and takes one? Hold her down?

You may understand pharmacy, but you do not understand the law. You are a learned intermediary and if if he dies, you will be sued and you will have no legal protection.

 

[tungsten87]

One of my top 10 favorite games. Mother 3 was even better. Different, but I liked it.

did you play mother 3 on GBA or did you use an emulator? was it translated to english? so happy to see another earthbound fan. if you've played MGS2 (even if you haven't) this would be an interesting read for you:

http://www.largeprimenumbers.com/article.php?sid=mother2

 

[apteryx]

I emulated it (don't speak Japanese, unfortunately.) I followed the starmen.net mother 3 blog the entire time tomato was working on the translation patch. The ENTIRE time, checked the blog once a day. I just told my buddy yesterday I need to do an earthbound and mother 3 playthrough before classes start this fall.

 

[apteryx]

Oh my god, I just marathon-read that entire thing, MY EYES. It was pretty good. Yeah, I have played MGS2. After reading that, it makes Japanese game developers seem pretty sadistic now, lol.

 

[njac]

I don't know about waiting in the car. I guess it depends on what the car's status is. If it's leaking gasoline or is smoking, I don't care if I break a vertebrae in the process, I'm gonna pull the person out of there.

no ****, really? You honestly think I meant leaving someone with a broken neck in a burning car?

 

[tungsten87]

I emulated it (don't speak Japanese, unfortunately.) I followed the starmen.net mother 3 blog the entire time tomato was working on the translation patch. The ENTIRE time, checked the blog once a day. I just told my buddy yesterday I need to do an earthbound and mother 3 playthrough before classes start this fall.

wow, I would absolutely love to play mother 3. would you mind giving me some brief instructions on which emulators to download, roms, translations, etc. im on a mac btw.

 

[rph3664]

I witnessed a car accident today involving an elderly woman and another family that rear ended her. She walked herself over to the curb and then all of a sudden started crawling on the ground by the grass. There were no visible signs of injury- from the looks of it just whiplash but she was hyperventilating and crying. There was a nurse that stopped and helped her. With all this schooling in the medical field I feel like I should be able to do more than just ask her what medications she's on and if she had any other health conditions. 🙁

What other things do you think pharmacists can do in emergency situations like this?

Really, the only thing you should do is be a good bystander and call 911, and then stay out of the way when EMS arrives.

 

[rph3664]

Don't forget your ABC's

The the challenge comes when something happens in your pharmacy and you
are faced with taking care of your ailing customer or covering your butt.

Case in point; a woman came into my pharmacy with an impending allergic
reaction to shellfish. She was barely able to make it to the waiting area chairs
with assistance. Paramedics arrived before she really went south, but the thought crossed my mind that benadryl and an epi-pen were only 15 feet away. What would YOU have done had she stopped breathing? Keep counting and pouring? Do basic life support? Or jump over the counter and administer the epi-pen thus breaking the law?

Wouldn't administering the Epi-Pen be practicing medicine without a license? 😕

When I worked in retail, I did once have a colleague who gave some nitro pills to a person in the store who was having chest pain while he was working on the weekend, then got the doctor's name and got a prescription on Monday morning. This is permissible, in part because it's not an invasive procedure and nobody I know of takes nitroglycerin for fun.

 

[vash1012]

I think if you look at the two examples of chest pain and an obvious allergic reaction you will see two opposite sides of this issue. Giving a NTG for chest pain doesn't make any sense since its not going to improve the person's chance of survival and may harm them if they took any viagra and don't want to admit it. In the case of an allergic reaction, an epi pen may save their life in an anaphylactic reaction and I've never seen a situation where a physician chose not to give epi in that situation. Personally, if I were in a rural pharmacy a long way from a hospital and my wife started having an anaphylactic reaction, I would sue you for negligence if you DIDNT give me a damn epi pen.

 

[owlegrad]

If you give an Epi-pen w/o an order, you have committed a crime at worst, or violated your state's regulations at worse. Since you are a health professional and not a "Good Samaritan" your insurance would not cover this either if the patient went south and died.

As a pharmacist, you have certain training and you have to know when it's OK to do something and when you have let somebody else do it. This would be one of those times to bow out...

Why wouldn't your insurance cover this? Do you mean professional malpractice insurance or some other insuranve? I am not a lawyer but I think it should cover this. What does malpractice insurance cover if not malpractice? I also wanted to point out that you gave two alternatives, both of which were the worst.

 

[All4MyDaughter]

Personally, if I were in a rural pharmacy a long way from a hospital and my wife started having an anaphylactic reaction, I would sue you for negligence if you DIDNT give me a damn epi pen.

Your suit would most likely not be successful. It is not negligence to refuse to do something that you are legally constrained from doing to begin with. Old Timer is correct that giving an Epi Pen in that situation is illegal.

Why wouldn't your insurance cover this? Do you mean professional malpractice insurance or some other insuranve? I am not a lawyer but I think it should cover this. What does malpractice insurance cover if not malpractice? I also wanted to point out that you gave two alternatives, both of which were the worst.

Your professional liability insurance covers you for malpractice WITHIN your scope of practice. Diagnosing an anaphylactic reaction and prescribing/administering medication to treat it is not within the PharmD's scope of practice.

 

[confettiflyer]

Oh please. Acting in the best interest of the patient is all that matters. No jury will convict you for giving an Epi-Pen to a guy holding his throat, gasping for breath and with rash all over his body with a wife crying and saying that he got stung by a bee. Hell what are you going to do when the wife jumps over the counter and takes one? Hold her down?

Jury won't convict, but that doesn't matter, you will be bankrupted by legal fees before your case even goes to trial. The "out of scope" provision discussed above means you're on your own legally.

Conversely, this will probably protect you as the plantiff will have no use trying to sue someone without deep pockets. They'll sue your employer, settle for a ton of money, and you'll be out in the cold most likely terminated & unable to find a new job.

Jury trial....bwaahahahahah...another naive person thinking justice is served by a 12 member jury of their peers and not at a conference table full of attorneys.

 

[Sparda29]

You may understand pharmacy, but you do not understand the law. You are a learned intermediary and if if he dies, you will be sued and you will have no legal protection.

Then the law needs to be changed to allow people to go out of their scope of practice in emergency situations.

 

[owlegrad]

Your professional liability insurance covers you for malpractice WITHIN your scope of practice. Diagnosing an anaphylactic reaction and prescribing/administering medication to treat it is not within the PharmD's scope of practice.

Thanks for clearing that up for me. The only thing I find odd about that argument is the idea that it is ever within your scope of practice to commit malpractice. I guess you mean that it covers dispensing errors or maybe consultation errors, not practising medicine without a license "errors"?

 

[All4MyDaughter]

Then the law needs to be changed to allow people to go out of their scope of practice in emergency situations.

No. Scope of practice is defined by what someone is trained to do. If health care professionals are allowed to throw caution to the wind and go outside of scope in an emergency, who is going to be liable for the inevitable bad outcomes?

 

[owlegrad]

No. Scope of practice is defined by what someone is trained to do. If health care professionals are allowed to throw caution to the wind and go outside of scope in an emergency, who is going to be liable for the inevitable bad outcomes?

I don't know about this, who is held liable for the bad outcomes of not intervening? I hate to sound like a naive student, but what about what's best for the patient? Seems like there must be a duty to do all you can to save a life. If intervening has the potential to save a life, I can't imagine ignoring them. Sorry about your father kid he was outside my scope of practice. The obsession with liability seems unhealthy (says the student who doesn't have to worry about it yet).

 

[nlax30]

I don't know about this, who is held liable for the bad outcomes of not intervening? I hate to sound like a naive student, but what about what's best for the patient? Seems like there must be a duty to do all you can to save a life. If intervening has the potential to save a life, I can't imagine ignoring them. Sorry about your father kid he was outside my scope of practice. The obsession with liability seems unhealthy (says the student who doesn't have to worry about it yet).

No such legal duty. Ethically as a human it would be hard not to intervene but outside the scope of practice with no legal duty to act you are not "obligated" to intervene.

Crap happens and people die, but doesn't mean that someone has to be liable for every bad outcome.

Is an interesting question though. Anybody know if there's been any case law on this type of scenario?

 

[confettiflyer]

Then the law needs to be changed to allow people to go out of their scope of practice in emergency situations.

slippery slope. MI is an emergency, does that mean i can cath someone in my garage and put in a stent because my neighbor had a STEMI in his front yard?

besides, now you don't need to hire ED docs/nurses. Just have a bunch of pharmacists and medical assistants staffing the ED since, well, hey it's an emergency situation...anyone can practice anything in there.

 

[awval999]

You may understand pharmacy, but you do not understand the law. You are a learned intermediary and if if he dies, you will be sued and you will have no legal protection.

Ohio Revised Code: 2305.23

Liability for emergency care.
No person shall be liable in civil damages for administering emergency care or treatment at the scene of an emergency outside of a hospital, doctor’s office, or other place having proper medical equipment, for acts performed at the scene of such emergency, unless such acts constitute willful or wanton misconduct.

Nothing in this section applies to the administering of such care or treatment where the same is rendered for remuneration, or with the expectation of remuneration, from the recipient of such care or treatment or someone on his behalf. The administering of such care or treatment by one as a part of his duties as a paid member of any organization of law enforcement officers or fire fighters does not cause such to be a rendering for remuneration or expectation of remuneration.

Do you see where it says "no person."

In addition I have a multi-million dollar umbrella liabilty policy. I shall continue to give away Epi-pens in emergency situations in the great state of Ohio for all-time.

 

[njac]

Ohio Revised Code: 2305.23

Liability for emergency care.
No person shall be liable in civil damages for administering emergency care or treatment at the scene of an emergency outside of a hospital, doctor’s office, or other place having proper medical equipment, for acts performed at the scene of such emergency, unless such acts constitute willful or wanton misconduct.

Nothing in this section applies to the administering of such care or treatment where the same is rendered for remuneration, or with the expectation of remuneration, from the recipient of such care or treatment or someone on his behalf. The administering of such care or treatment by one as a part of his duties as a paid member of any organization of law enforcement officers or fire fighters does not cause such to be a rendering for remuneration or expectation of remuneration.

Do you see where it says "no person."

In addition I have a multi-million dollar umbrella liabilty policy. I shall continue to give away Epi-pens in emergency situations in the great state of Ohio for all-time.

I've been taught by multiple people not to carry extra liability insurance because it does make you a target for litigation. They aren't going to go after me, with a $15K car a my only asset. You with the potential for a couple million? Sweet, that's worth trying for.

 

[awval999]

I've been taught by multiple people not to carry extra liability insurance because it does make you a target for litigation. They aren't going to go after me, with a $15K car a my only asset. You with the potential for a couple million? Sweet, that's worth trying for.

I know. Because a 100K salary for the next 40 years isn't worth going after. You do understand that you can have a wage garnishment verdict handed against you right?

In full disclosure I only have a 1MM umbrella. It's like a hundred dollars or so a year.

In addition the liability insurance covers your attorney's fees, as the insurance company will attempt to protects its 1MM in potential costs. Just note that umbrella liability insurance only protects against non-professional verdicts, like car crash, injury on property, etc. You need professional insurance, like through Pharmacists Mutual to protect against errors on the job.

 

[All4MyDaughter]

Thanks for clearing that up for me. The only thing I find odd about that argument is the idea that it is ever within your scope of practice to commit malpractice. I guess you mean that it covers dispensing errors or maybe consultation errors, not practising medicine without a license "errors"?

My understanding is that malpractice insurance would cover you for errors made as a PHARMACIST. If I try to do surgery in the back room at my pharmacy, that is not the practice of pharmacy and my insurance company (Pharmacist's Mutual) is not going to want to pay. I'm also breaking the law.

I don't know about this, who is held liable for the bad outcomes of not intervening? I hate to sound like a naive student, but what about what's best for the patient? Seems like there must be a duty to do all you can to save a life. If intervening has the potential to save a life, I can't imagine ignoring them. Sorry about your father kid he was outside my scope of practice. The obsession with liability seems unhealthy (says the student who doesn't have to worry about it yet).

What is best for the patient? People with appropriate training doing appropriate procedures to save lives. Not people being cowboys trying to do things they aren't trained for.

If I choke on food in my home and die, no one is responsible for that bad outcome. If I choke on food in a restaurant and some nurse decides to try to trach me with a straw b/c she saw it on TV and I get an infection or bleed to death or have a severed windpipe, she's going to be held responsible for practicing emergency medicine without a license. She's also going to get sued by me and I'll probably win.

Ohio Revised Code: 2305.23

Liability for emergency care.
No person shall be liable in civil damages for administering emergency care or treatment at the scene of an emergency outside of a hospital, doctor's office, or other place having proper medical equipment, for acts performed at the scene of such emergency, unless such acts constitute willful or wanton misconduct.

A health care professional providing emergency care or treatment outside of their legally defined scope of practice could be considered willful or wanton misconduct.

If nothing bad happens b/c you gave away an Epi-Pen without an RX, that's great. No harm, no foul. No loss of life or injury = no damages. However, you could still be charged with practicing medicine without a license. But you can bet that if your Epi-Pen causes injury or death you will NOT be protected from civil and possibly criminal liability b/c the law you quote above specifically does not shield willful or wanton misconduct.

The great state of Ohio recently put a pharmacist in jail. I'd be cautious.

 

[owlegrad]

What is best for the patient? People with appropriate training doing appropriate procedures to save lives. Not people being cowboys trying to do things they aren't trained for.

If I choke on food in my home and die, no one is responsible for that bad outcome. If I choke on food in a restaurant and some nurse decides to try to trach me with a straw b/c she saw it on TV and I get an infection or bleed to death or have a severed windpipe, she's going to be held responsible for practicing emergency medicine without a license. She's also going to get sued by me and I'll probably win.

You are probably correct about the insurance.

I would argue that if you have the knowledge/equipment to save some one's life but choose not to due to possible legal consequences, that is not what is best for the patient. Yes the best thing is for every bad thing to happen when close range of trained medical personnel, but that's not always the case and is not really what is being discussed.

No one is talking about what happens when you choke alone. I agree that no one is at fault here (except maybe you - remember to chew 32 times!).

On the other hand if she saved your life, you would thank her. You are taking it to an illogical extreme anyway. She would give the heimlich maneuver not try to trach you. Giving life saving intervention (heimlich)and trying to play MAcGyver with some one's life (emergency trach) are not the same thing.

 

[rxlea]

Hello 2004