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shakylegs
Nov 24, 2004, 10:00 PM
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Hopefully someone knowledgeable will be able to answer this: Scenario: I’m midway up a multi-pitch and am at least two full-length rappels from the bottom, and a good 45-60 minute hike out. Being the safe boy that I am, I’ve got two epi-pens with me. I have the misfortune of reacting to whatever it is I’m allergic to, say a bee-sting or something I ate. Realizing what’s happening, I jab the first epi-pen into my thigh. That’s good for about 15 minutes. We start heading down, and I feel the anaphylactic shock symptoms arising again. So I use up the second epi-pen, which is pretty much the limit of what you should take. So, now, am I screwed, or will the double doses of adrenaline be enough for me to get me out of there? For arguments' sake, I also have some Benadryl with me.
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johnathon78
Nov 24, 2004, 10:08 PM
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I'd say that if after 2 epi-pens you still suffer horrible side effecs from your ellergic reaction you should'nt be out there in the first place. The first one should've at least ceased the reaction to allow you to get down and out without the use for the second. If you suffer bad reactions from an object outside, maybe you should stick to the indoors walls.
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alpnclmbr1
Nov 24, 2004, 10:14 PM
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The standard wfr beta is to shoot the epi pen, then take the benadryl. The benadryl takes effect in 15 to 20 minutes I do know that you can get more then one shot out of some pens. I do not know what the proper procedure is on multiple shots. I do know that it seems to work like a magic bullet most of the time.
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sandbag
Nov 24, 2004, 10:17 PM
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what the hell did you eat mid route that caused anaphylaxis? t2 at best
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winglady
Nov 24, 2004, 10:18 PM
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Yipes --- don't you think this is more a question for your DOCTOR than for a forum where g*d-knows-who is trying to answer your question?
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rockgrl
Nov 24, 2004, 10:21 PM
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I'm in the same situation...allergic to wasps, carry two epi pens. I'm typically no more than a 20 minute hike to the car, but I try to stash a cell phone somewhere nearby so an ambulance can be called to meet me at the bottom if needed. I don't think you can ever really know how long the first or the second shot will last you and it could be different every time, but then again, I'm not a doctor. This is just what I've heard.
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shakylegs
Nov 24, 2004, 10:33 PM
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In reply to: what the hell did you eat mid route that caused anaphylaxis? t2 at best There's this weird thing, called gorp, aka trail mix. You may have heard of it. It's often a mixture of nuts, which, hey, what do you know, can cause anaphylaxis. And t2 are my ski boots. Try a bit harder next time.
In reply to: Yipes --- don't you think this is more a question for your DOCTOR than for a forum where g*d-knows-who is trying to answer your question? Take a look at other threads in this forum; quite often there are doctors who respond, who are also climbers. Weird, ain't it? And, just to help you with that icky thing called comprehension, take a look at the first line on the original post. Hell, I'll save you the scroll: "Hopefully someone knowledgeable will be able to answer this." Thanks to the others for your responses.
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sandbag
Nov 24, 2004, 10:42 PM
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In reply to: In reply to: what the hell did you eat mid route that caused anaphylaxis? t2 at best There's this weird thing, called gorp, aka trail mix. You may have heard of it. It's often a mixture of nuts, which, hey, what do you know, can cause anaphylaxis. And t2 are my ski boots. Try a bit harder next time. In reply to: Yipes --- don't you think this is more a question for your DOCTOR than for a forum where g*d-knows-who is trying to answer your question? Take a look at other threads in this forum; quite often there are doctors who respond, who are also climbers. Weird, ain't it? And, just to help you with that icky thing called comprehension, take a look at the first line on the original post. Hell, I'll save you the scroll: "Hopefully someone knowledgeable will be able to answer this." Thanks to the others for your responses. OOOOOK mr asshat. If youre stupid(not ignorant) enough to buy food that youre not sure of knowing you suffer from an anaphylaxis, then have at it. Im sure an EMT out there is just dying to get a chance to do an in the field tracheotomy, I know id like to give it a shot someday. Ive never met an adult that just eats food, GORP or otherwise and conceals their allergy or ignores the consequences for not knowing what they are eating. So if youre going to post a redundant thread, at least have a modicum of common sense onthe topic and then again........... wheres JT512 wehn we need him.....close this thread.........
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climbingnurse
Nov 24, 2004, 10:48 PM
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OK, first, my standard disclaimer: I am not a nurse. I won't graduate from nursing school for another 5 months and 27 days. Besides that I offer no guarantees that anything I tell you is correct. I'll do my best though. Here goes: Epinephrine given for anaphylaxis is usually dosed at 0.3 mg (more than likely what is in your epi-pin) every 10 to 15 minutes. According to my Nurse's Drug Guide the onset should be in 3 to 5 minutes and the peak action of the drug should be at 20 minutes. If you treat anaphylaxis with epinephrine, it is standard practice to immediately follow the injection with 50 mg (usually two pills) of Benadryl (or a generic substitute) by mouth. That drug will take 15 to 30 minutes to onset and the peak will last from 1 to 4 hours. So, that's why you carry two epi-pins. It is possible that the first dose of epi will wear off before the benadryl kicks in. If that happens, you give the second dose of epi. You shouldn't need more than those two doses assuming no more than one person goes into anaphylaxis and you are able to get benadryl into the person in anaphylaxis. Now, some general advice: -Don't try rappelling until you (or whoever is in anaphylaxis) is stable. That might mean waiting 30 minutes for the Benadryl to kick in. -Try to arrange to sit down with a licensed medical professional to talk this out and discuss your strategy. -If you are trying to decide whether to take the epi-pin or the Benadryl with you, I'd highly recommend the Benadryl -I think its fairly safe to say that johnathan78 has no idea what he's talking about Source: Wilson, B.A., Shannon, M.T., Stang, C.L.. (2004). Nurse’s Drug Guide. Upper Saddle River, NJ: Prentice Hall.
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jammer
Nov 24, 2004, 10:50 PM
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Folks, this could get ugly!
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climbingnurse
Nov 24, 2004, 11:05 PM
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Just wanted to clarify something about the difference between epinephrine and Benadryl and why they are both used the way they are to treat anaphylaxis... Epinephrine doesn't stop the allergic reaction, it just counteracts some of the symptoms. When the epi effect wears off (in about 20 minutes or so), the person in anaphylaxis will immediately start having the symptoms again. Benadryl actually stops the allergic reaction. It is a much more effective remedy except that you have to take it by mouth* which means at least 15 minutes to take effect. That's not so good if you are unable to breath or going into shock because you'll be long dead in 15 minutes. *Benadryl is actually available in an injectable form. We give it to people who have bad reactions to anti-psychotic medications all the time. I've never been real clear on why we don't use it as such to treat anaphylaxis. Anybody know why this is?
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reno
Nov 24, 2004, 11:07 PM
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[mod] Watch the personal attacks, gang. Do it elsewhere, but not in this forum. [/mod] That having been said, Epi is one of those strange medications. It's made by the body, but the body typically releases only as much as it needs. Those of us in medicine, in all our self-aggrandizing ways, decided on a "One-size-fits-all" approach, and make Epi pens with a standard dose (actually, there are TWO different sizes... one with 0.3 mg Epi, and one with 0.5mg Epi.) Now... As long as you meet the criteria below, you're *probably* safe taking two doses. Perhaps even three. But if I, as a paramedic, had a patient that needed more than 3 doses of Epi, I'd be thinking one of two things: This is the worst allergic reaction in the history of medicine, or this isn't an allergic reaction but something else that looks like an allergic reaction. The criteria: No history of coronary artery disease; no history of hypertension; no history of congestive heart failure, cardiac hypertrophy, or other cardiomyopathy; under the age of 45; no recent stroke or brain surgery; no kidney failure. If I were in such a situation, I'd have done the following: ~Dose the first Epi-pen. ~Then take a Benadryl (if you have the capsules, break it open and dump the powder under your tongue and let it dissolve. Works faster.) ~Start making fast tracks for the car and a hospital. ~Take the second Epi-pen when the symptoms got worse. ~Take a second Benadryl at the same time. ~Pray. Moving fast will help the body create it's own natural adrenaline (Epi.) That might buy you some time. (A good friend of mine was caught unprepared at the bottom of the Black Canyon of the Gunnison when he got stung. He blasted up the wall in near record time, and was OK when he got to the top. I think that is due, in part, to his "Oh, shit... I gotta get up and out of here, fast" reflex. Fight/flight thing. His body probably produced a lot of adrenaline, and that staed off the allergic reaction.)
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reno
Nov 24, 2004, 11:10 PM
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In reply to: *Benadryl is actually available in an injectable form. We give it to people who have bad reactions to anti-psychotic medications all the time. I've never been real clear on why we don't use it as such to treat anaphylaxis. Anybody know why this is? We give IV or IM Benadryl for allergic reactions all the time in the EMS arena. It kinda makes the doctors mad, cause now they have to watch for S/Sx of anti-cholinergic OD, but better that than a dead patient. I'll carry parenteral Benadryl in my medi-bag when doing remote, backcountry, or alpine routes. Syringe, too. But then, I've got a doctor who will approve my using it, so I'm safe, from a legal standpoint.
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mtn_eagle
Nov 24, 2004, 11:51 PM
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Anaphylaxis is an immediate allergic reaction to a substance that you have previously been sensitized. No one's sure why some poeple are prone to this. IgE binds to the antigen and activated mast cells that release a variety of inflammatory mediators including histamine. The reason it kills you is usually due to a collapse in blood pressure as the blood vessels all dilate and you become relatively hypovolemic or due to swelling of the upper airways which causes asphyxia. Skin reactions, nausea/vomiting, headaches, fainting, wheezing and flushing are other common symptoms. There are also anaphylatoid reactions that are not mediated by IgE and do not require desensitization. Inherited disorders like C 1 esterase deficiency can result in recurrent anaphylaxis and is very difficult to treat. Other rare conditions can include exercise induced anaphylaxis and cold induced anaphylaxis (bad for ice-climbers). As the others have suggested, consider not being more than 15-20 minutes from where emergency medical personnel can reach you and always have a cell phone with you. I would suggest taking up sport cilmbing or bouldering. If you still want to do long routes, you take your life in your own hands. I'd suggest seeing an allergist to make a plan. Don't screw around with this. You could die. Ask him or her about epi-pens, benadryl, ranitidine/cimetidine, glucagon, albuterol, atrovent and prednisone. Based on what you are allergic to they may also consider desensitization therapy. This has risks and takes several weeks to complete but can be very effective.
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climbingnurse
Nov 25, 2004, 12:46 AM
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mtn_eagle, first you offer an overly technical explanation of anaphylaxis and then you make this statement:
In reply to: As the others have suggested, consider not being more than 15-20 minutes from where emergency medical personnel can reach you and always have a cell phone with you. I would suggest taking up sport cilmbing or bouldering. WTF? You don't even know if this guy (shaky_legs) is actually allergic to anything, let alone how bad his allergy is. Suddenly he needs to become a boulderer? What a horrible fate to so randomly and glibly assign to someone. Allergies can be managed in a wilderness setting with the appropriate training and equipment. Why not encourage him to take a wilderness medicine class or something? (fights urge to make nasty comments and ends post here)
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kman
Nov 25, 2004, 12:59 AM
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In reply to: what the hell did you eat mid route that caused anaphylaxis? t2 at best :roll: Here we go. You can also be alergic to stings, bites, plants...basically anything. Take a WFR course.
In reply to: Yipes --- don't you think this is more a question for your DOCTOR than for a forum where g*d-knows-who is trying to answer your question? Just calm down there. It's a pretty standard first aid question. Take the epi-pen then benadryl just like the climbing nurse said. And the rest of you just need to chill out and go take some first aid courses or something.
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flamer
Nov 25, 2004, 1:28 AM
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In reply to: Moving fast will help the body create it's own natural adrenaline (Epi.) That might buy you some time. (A good friend of mine was caught unprepared at the bottom of the Black Canyon of the Gunnison when he got stung. He blasted up the wall in near record time, and was OK when he got to the top. I think that is due, in part, to his "Oh, s---... I gotta get up and out of here, fast" reflex. Fight/flight thing. His body probably produced a lot of adrenaline, and that staed off the allergic reaction.) Guilty. In the situation reno mentioned I think one of 2 things kept me from having an anaphylatic reaction.(I already knew I was allergic to bee's but have never had an anaphylatic reaction). #1- I may not have been allergic to the type of bee that stung me- we think it was a European wasp(damn euro's!!) OR #2 As reno mention I high tailed it out of there....nearly running up the cruise gully, freesoloing everything I only stopped once to fix a rope on the more difficult of the 2 rappels, for my partner. My adrealine was seriously pumping. I do remember at one point thinking my throat was starting to swell, but I blocked it out and pushed even harder up the gully. At the top the climbing ranger was in the ranger station and gave me a double dose of Benedryl as soon as I got there- Thanks Brent!! I ended up being fine. I always carry benedryl, but I don't always carry Epi...I'm not recommending this, but Epi pens expire every what 3? 6? months I don't see a doctor that regularly and so I have alot of expired Epi!! My advice??? Don't get stung!! josh
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cbare
Nov 25, 2004, 1:47 AM
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I think all of the posts really demonstrate one thing. Anaphylaxis is a very complex medical problem, ( actually syndrome may be a better way to describe) and it is good that we do not limit ourselves to one particular way of treating the problem. As for food or sting or what ever the cause, the odvious treatment is prevention, but no one wants to live in a plastic bubble so we must find some kind of compromise for dealing with our various problems. Anaphylaxis is the most severe form of an allergic reaction. Anaphylaxis is the body's response to a material it thinks is antigenic (harmful/disease producing) While this respons is a good thing, people who develop anaphylaxis over produce an antibody called IgE. An antibody is an immune system product that helps the body identify antigens. Unfortunatly, the massive amounts of IgE attach to special cells called basophils ( special white cells circulating in the blood) and mast cells (special immune cells in tissue that sorrounds blood vessels). The IgE remains dormant until the next exposure to the antigenic material. Once the person is expose to the antigen, the antigen reacts to the IgE antibody. Unfortunatly this reaction occurs violently an all over the body. The reaction causes the basophils and mast cells to degrade and release massive amounts of chemical messangers that trigger the massive immune response. Yes histamine is on of these, however, several other chemicals like leukotrienes and eosinophil chemotactic factor of anaphylaxis among many others are also released. Histamine is talked about most often because it directly acts upon blood vessels causing them to leak large amounts of fluid. So, with all of this you will die in essentially two ways. First, fluid leaking into the airway and swelling of the airway will cause death the fastest. Second, the rapid loss of fluids from the blood vessels causes a sudden loss of pressure in the vascular system. It is kind of like getting shot, you loose allot of fluid, only it does not gush from an open wound, it leakes out into the tissues of the body. Hence, some people will call this circulatory collapse or I simply like to call it "really bad shock." Ok enough with the bio 101 lecture. At least everybody agrees on one thing. Epinephrine is the only medication that will immediatly treat the life threatening aspects of anaphylaxis. This is where we administer the epi pen. It has a typical adult dose of 0.3mg given in the vastus lateralus (thigh) muscle. And many epi pens come in a kit of two loaded syringes and a trainer. This is where people get bent aroud the axle. Give two epi pens, take benadryl, give steroid, etc, etc. There are too many algorhythms to count for treating anaphylaxis. Primary treatment should be give the epi pen. Then, it gets rather subjective. Epinephrine dos not have a long half life so in people with refractory (resistant) anaphylaxis a repeat dose of epinephrine may be required. Benadryl to help inhibit the effects of histamine is good. I think reno wrote to open the capsule and give under the tongue. Brilliant, that's all I can say. (Faster absorption) Someone else wrote about injectable benadryl, if you have a doctor who will allow this, it is definatly the way to go. Generally this is how treatment occurs in my emergency room. Epinephrine to stabilize the good old ABC's. Typical dose 0.3-0.5mg subcutaneus injection Benadryl 50mg muscular injection-this will help antagonize histamine and acts longer than epinephrine Possibly an inhaled bronchodilator to assist with clearing the airway--something like albuterol oe xopenex An injection of a long acting steroid to prevent a delayed reaction--Solumedrol 125 mg iv works nicely. Sometimes followed up with oral steroids (Medrol Dose Pack) Sometimes in severe cases we have to give IV epinephrine 1-2cc of 1:10,000 concentration, not the 1:1,000 concentration found in epi pens. Does this always work, nope. Sometimes we have to add a couple grams of magnesium sulfate to the IV to help relax and open up the muscles of the airway. And someone mentioned a medication for heart burn or GERD cimetidine. Is he totally crazy? not at all. Sometimes a medication like zantac given IV is quite helpful for it's antihistamine properties. I guess the meaning of all of this is there are allot of ways to treat an individual in anaphylaxis. The best advice is to say what someone allready said, get with a specialist and find out what will work for you in a given scenario, epi pen+benadryl+steroid or even immuno-therapy. Good luck, hope this is not too long and it helps. Chris Bare. sorry about the typos
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boltdude
Nov 25, 2004, 2:08 AM
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As long as we're on the subject, I've been stung probably 50 times by honey bees and yellow jackets (once 8 times in the head and neck at the top of E Butt of Middle Cathedral), and until last year, never had any reactions. Last year, I got stung about 6-8 times (within 10 seconds) by yellow jackets in Tenaya Canyon, and about 2-3 days after being stung, the small welts grew to around 2-3" diameter and itched like crazy. They eventually went away after around 2 weeks (I used 0.5-1% hydrocortisone anti-itch cream). Anyway, any guesses as to my chances of developing more serious reactions? I've tried to carry Benadryl tablets around since then, but haven't been that serious about making sure I always have them quickly available.
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reno
Nov 25, 2004, 3:43 AM
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In reply to: Last year, I got stung about 6-8 times (within 10 seconds) by yellow jackets in Tenaya Canyon, and about 2-3 days after being stung, the small welts grew to around 2-3" diameter and itched like crazy. They eventually went away after around 2 weeks (I used 0.5-1% hydrocortisone anti-itch cream). Anyway, any guesses as to my chances of developing more serious reactions? I've tried to carry Benadryl tablets around since then, but haven't been that serious about making sure I always have them quickly available. Boltdude: This is a touchy question for the medical professionals on this list to answer. With the standard disclaimer in mind, I'd say "There's no way to tell." It's quite possible you could have a more profound reaction the next time you get stung. As a general rule, the reaction to any given substance (peanut oil, bee venom, etc.) gets worse the more often you get exposed. One bite is no big deal. The second bite is worse than the first. Third is worse than the second. And so on. A second subset of folks, like myself, do not have reactions at all. I've gotten a double sting to the same place (two bees, two stings, left side of my face, in about 30 seconds,) and didn't even swell any. Some folks are just fortunate to not have reactions. (FYI, this same concept applies to mosquito bites, poison ivy, etc. Some people just don't have any reaction to those substances at all.) The third, and final subset, are the folks that don't increase reactions with progressive stings. Sure, they might get a small welt, but that's it. Next sting... small welt. Third sting... small welt. You get the point. I can't tell you which group you fall into. Neither can anyone else, except perhaps an immunologist. Sorry.
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mtn_eagle
Nov 25, 2004, 4:46 AM
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In reply to: mtn_eagle, first you offer an overly technical explanation of anaphylaxis and then you make this statement: In reply to: As the others have suggested, consider not being more than 15-20 minutes from where emergency medical personnel can reach you and always have a cell phone with you. I would suggest taking up sport cilmbing or bouldering. WTF? You don't even know if this guy (shaky_legs) is actually allergic to anything, let alone how bad his allergy is. Suddenly he needs to become a boulderer? What a horrible fate to so randomly and glibly assign to someone. Allergies can be managed in a wilderness setting with the appropriate training and equipment. Why not encourage him to take a wilderness medicine class or something? (fights urge to make nasty comments and ends post here) Read the original post. He was asking about anaphylactic shock, not "allergies". If he was asking how to deal with itchy eyes and a runny nose when the pollen count is high, then disregard all I said and buy some benadryl. No one knows that they will have anaphylaxis until they have already had an episode, so I guess I was assuming that he had had an episode in the past and that was why he was carrying epi pens in the first place. I wouldn't be so quick to underestimate the intelligence of other people on this site. I suppose some may have to look up the words "hypovolemic" and "mast cell" but the rest seems comprehendable to me. Also, I think your inexperience shows in your own advice. You seem to imply that a couple shots of epi and some benadryl and everything will be OK for someone experiencing anaphylaxis. Anaphylactic shock is often much more severe requiring several liters of IV fluids and pressor infusions to keep the blood pressure up. And there's not much that tightens the sphinctor more than trying to squeak an entotracheal tube past a swollen airway while the ENT surgeons are hovering for the crash tracheostomy if I miss. Anyways, why so hostile, dude?
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reconbeef
Nov 28, 2004, 7:58 PM
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I agree, Shaky_Legs should never be more than 15-20 minutes from where emergency medical personnel can reach him and stick to sport cilmbing or bouldering. Even then, I think he should always boulder with at least 2 spotters and 3 crash pads. When sport climbing, never lead anything over 2 grades easier than what he can comfortably top-rope, and never climb on bolts that are over 5 years old. More importantly, Shaky, I think it's about time you gave up red meat, always wear your seat belt, wash you hands every time you use the rest room, get 8 hours of sleep a night and drink 6 glasses of water a day. Telling someone that their medical condition prohibits their ventruing into out doors does not only NOT answer the origional question (which was what do I do about potential anaphylaxis, not should I give up rock climbing) but is also not your counsil to give. This is a potentially dangerous sport, and we all make decisions and compromises on the safety vs. experience. If you want a 100% safe climbing experience, crack open a beer and watch Masters of Stone VXII. I've had partners with diabetes as well as a bee sting sensitivity, we both back and plan accordingly and go for it. The odds of my fat ass blowing a cam and decking are far higher than either of them having a medical problem. I think this is one area where urban, hospital-based, medicine and wilderness medicine come into conflict. The rules are different in the backcountry, and you go in realizing it. You take a risk when you go out of the comfort zone of the first world Medical Industrial Complex, and you realize that. The question is, once you have made that decision, how do you best prepare? Here, I think most of the posters have given sound advice. And all of the major Wilderness Medical groups are in pretty close agreement on preparing for and treating anaphylaxis in the backcountry. Epi-benadryl-epi-benadryl-epi... evac. Most of the cases I've had, both front and back country, this has been remarkably effective. The only times it hasn't, the person has been a serious asthmatic, who was on home oxygen. Again, on a philospohical note, you should realize that this might not work and you could die. If you're ok with that, climb on. If not, beer's in the fridge. -James
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sixleggedinsect
Nov 28, 2004, 8:36 PM
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In reply to: Hopefully someone knowledgeable will be able to answer this: Scenario: I’m midway up a multi-pitch and am at least two full-length rappels from the bottom, and a good 45-60 minute hike out. Being the safe boy that I am, I’ve got two epi-pens with me. I have the misfortune of reacting to whatever it is I’m allergic to, say a bee-sting or something I ate. Realizing what’s happening, I jab the first epi-pen into my thigh. That’s good for about 15 minutes. We start heading down, and I feel the anaphylactic shock symptoms arising again. So I use up the second epi-pen, which is pretty much the limit of what you should take. So, now, am I screwed, or will the double doses of adrenaline be enough for me to get me out of there? For arguments' sake, I also have some Benadryl with me. well, you leave some information out. first off, epi wont do jack in the longterm. all it does is save your life for a bit until the benadryl kicks in. you did not say, in your hypothetical situation, whether you took benadryl as soon as you felt the allergic reaction. if you could still talk normally, you shoudl have done this first, a double dose. if you whacked yourslef with the epi pen first, the next step is to take benadryl. only then should you start evacuating. if the benadryl doesnt kick in by the time the epi kicks out, then as you say, you should use the second dose. however, no more benadryl is advised. if the benadryl still hadnt kicked in by the time the epi's effects wore off, and you had another epi pen, that would be great. if you are experiencing life threatening allergic reactions, you can keep plugging epinephrine in. normal people stop at two or three in the rare circumstances in which repeat doses are needed only becuase they are limited to what they have with them. there are serious potential side effects to epinephrine, but they are far less serious than dying immediately from anaphylaxis. carrying an epi pen without bendryl (or its generic equivalents) is irresponsible. period. anthony
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sixleggedinsect
Nov 28, 2004, 8:45 PM
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In reply to: Now... As long as you meet the criteria below, you're *probably* safe taking two doses. Perhaps even three. But if I, as a paramedic, had a patient that needed more than 3 doses of Epi, I'd be thinking one of two things: This is the worst allergic reaction in the history of medicine, or this isn't an allergic reaction but something else that looks like an allergic reaction. The criteria: No history of coronary artery disease; no history of hypertension; no history of congestive heart failure, cardiac hypertrophy, or other cardiomyopathy; under the age of 45; no recent stroke or brain surgery; no kidney failure. i believe that it is inappropriate to even discuss the contraindictions of epinephrine in this context. reno, you work in EMS and have a different setup than a climber on a cliff somewhere who is absolutely under no way going to have access to plentiful IV drugs and airway ALS. while it is true that people with cardio risks are not your ideal epinephrine candidates, that DOES NOT MATTER because there is a good chance that the person suffering from a reaction this violent will die from it. there is only a slight chance we will precipitate a cardiac event.
In reply to: Moving fast will help the body create it's own natural adrenaline (Epi.) That might buy you some time. (A good friend of mine was caught unprepared at the bottom of the Black Canyon of the Gunnison when he got stung. He blasted up the wall in near record time, and was OK when he got to the top. I think that is due, in part, to his "Oh, s---... I gotta get up and out of here, fast" reflex. Fight/flight thing. His body probably produced a lot of adrenaline, and that staed off the allergic reaction.) i dunno man. i dont have any stats up my sleeve, but i am led to believe that the epi dose your body kicks out under dire circumstances is small beans compared to the hefty kick an epi pen will give.
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reno
Nov 28, 2004, 10:10 PM
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In reply to: In reply to: Now... As long as you meet the criteria below, you're *probably* safe taking two doses. Perhaps even three. But if I, as a paramedic, had a patient that needed more than 3 doses of Epi, I'd be thinking one of two things: This is the worst allergic reaction in the history of medicine, or this isn't an allergic reaction but something else that looks like an allergic reaction. The criteria: No history of coronary artery disease; no history of hypertension; no history of congestive heart failure, cardiac hypertrophy, or other cardiomyopathy; under the age of 45; no recent stroke or brain surgery; no kidney failure. i believe that it is inappropriate to even discuss the contraindictions of epinephrine in this context. reno, you work in EMS and have a different setup than a climber on a cliff somewhere who is absolutely under no way going to have access to plentiful IV drugs and airway ALS. while it is true that people with cardio risks are not your ideal epinephrine candidates, that DOES NOT MATTER because there is a good chance that the person suffering from a reaction this violent will die from it. there is only a slight chance we will precipitate a cardiac event. Define "small chance," please. The literature I've read is undecided on the situation, but by and large, "pre-existing cardiovascular disease" is a relative contra-indication to SC Epi. That doesn't mean you should never give it (SC Epi,) to a patient with a cardiac condition. It just means that you need to be really careful and understand the potential consequences, along with evaluating and weighing the entire situation (i.e. not every allergic reaction needs SC Epi.) I thought I made that clear. If not, then my apologies.
In reply to: In reply to: Moving fast will help the body create it's own natural adrenaline (Epi.) That might buy you some time. (A good friend of mine was caught unprepared at the bottom of the Black Canyon of the Gunnison when he got stung. He blasted up the wall in near record time, and was OK when he got to the top. I think that is due, in part, to his "Oh, s---... I gotta get up and out of here, fast" reflex. Fight/flight thing. His body probably produced a lot of adrenaline, and that staed off the allergic reaction.) i dunno man. i dont have any stats up my sleeve, but i am led to believe that the epi dose your body kicks out under dire circumstances is small beans compared to the hefty kick an epi pen will give. I do have the stats... During times of stress, the body can produce up to 4.0 (+/- 1.1) pmol/dL/min of endogenous adrenaline. Or, as a ballpark figure, 0.1 milligrams/min. Epi pens are 0.3 mg, and can be given every 5 minutes. Pretty close, if you ask me. Small wonder the fight or flight response works so well.
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sixleggedinsect
Nov 28, 2004, 10:46 PM
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In reply to: Define "small chance," please. The literature I've read is undecided on the situation, but by and large, "pre-existing cardiovascular disease" is a relative contra-indication to SC Epi. That doesn't mean you should never give it (SC Epi,) to a patient with a cardiac condition. It just means that you need to be really careful and understand the potential consequences, along with evaluating and weighing the entire situation (i.e. not every allergic reaction needs SC Epi.) I thought I made that clear. If not, then my apologies. thank you for the epi self-dose stats. where did you find that number? i definitely learned something today, and i'd like to know the source so i can pass it on. re: your justification of discussing epi contraindiction. i stand by what i said. above you mention SC (subcutaneous) injection of epinephrine. SC delivery is an urban protocol. in the woods, most folks either have epi pens (automatic IM intramuscular delivery) or are trained to draw up epi manually, for IM delivery. perhaps SC injection, which I know little about, is a slower delivery method, scaled to urban critical care protocols where you have all the toys on hand. perhaps contraindications are relevant there becuase you woudlnt use SC delivery if it was an immediately emergent reaction. i woudlnt know. but i do know that in the real world, if you have a life threatening reaction, you shoudlnt waste a second thinking about contraindications, and doctors will back me up on that. i dont have much time to browse, but sample from emedicine (http://www.emedicine.com/EMERG/topic25.htm) "May be administered in life-threatening anaphylactic reactions, even when the following relative contraindications are present: (1) coronary artery disease, (2) uncontrolled hypertension, (3) serious ventricular arrhythmias, and (4) second stage of labor" in the woods, either the reaction is life threatening, in which case you give them epi and take it from there. or is isnt life threatening right now, in which case you give them benadryl and proceed with caution. unless you are packing a lot of EMS credentials and a lot of gear, a rare combination in the woods, you won't diddle around with SC injections, contraindications, or the like. anthony
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reno
Nov 28, 2004, 11:15 PM
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Anthony: Good arguments. I'd like to address them in order, for clarity sake.
In reply to: thank you for the epi self-dose stats. where did you find that number? i definitely learned something today, and i'd like to know the source so i can pass it on. The numbers were floating around in my head from my pharmocolgy classes long ago in paramedic school. You could also do a search on the new Google Scholar (it's under the "more" when you go to Google's home page.) Searches scientific literature. Easier than MedLine, IMHO. Try "Endogenous adrenaline" as a search term.
In reply to: re: your justification of discussing epi contraindiction. i stand by what i said. above you mention SC (subcutaneous) injection of epinephrine. SC delivery is an urban protocol. in the woods, most folks either have epi pens (automatic IM intramuscular delivery) or are trained to draw up epi manually, for IM delivery. This is a common misconception. Epi Pens are not IM injections, but are actually SC injections (ever see the needle of an Epi Pen? Ain't long enough to go IM, unless you're overly famished and have ZERO body fat (even well conditioned athletes have a small degree of body fat... now whether they admit it or not is a different story!)
In reply to: but i do know that in the real world, if you have a life threatening reaction, you shoudlnt waste a second thinking about contraindications, and doctors will back me up on that. Perhaps true. Perhaps not. I know that I, as do many of my colleges, always take a moment (even if it is just a few seconds,) to think of the options. It's good medicine. Performing an intervention without considering the ramifications is a bad idea. Kinda like placing gear. You get in a situation, consider the options, and pick the best one. How fast you go through all those steps depends a great deal on the severity of the situation and your personal experience. Since I can not possibly teach someone all they need to know about Epi in a forum such as this (see below,) I am relegated to giving some broad info, and imploring the reader to do more research, including having such a discussion with their physician.
In reply to: "May be administered in life-threatening anaphylactic reactions, even when the following relative contraindications are present: (1) coronary artery disease, (2) uncontrolled hypertension, (3) serious ventricular arrhythmias, and (4) second stage of labor" Key word here is "relative." And, it goes on to say that "Adverse effects include cardiac ischemia or arrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid hemorrhage; use with caution in elderly and in patients that have diabetes mellitus, hyperthyroidism, prostatic hypertrophy, hypertension, cardiovascular disease, and cerebrovascular insufficiency; rapid IV infusions also may cause death from cerebrovascular hemorrhage or cardiac arrhythmias" Which is pretty much what I said (minus the part about elderly and prosatic hypertrophy... ) For those that are not aware, eMedicine.com is a FANTASTIC resource for medical info. Be warned that it might be more than you wanted (the authors like to delve deep into some topics, so unless you have a medical education, it might be over your head,) but all the info is accurate and fairly current. It requires registration, but that is free and I've not gotten much SPAM as a result.
In reply to: in the woods, either the reaction is life threatening, in which case you give them epi and take it from there. or is isnt life threatening right now, in which case you give them benadryl and proceed with caution. unless you are packing a lot of EMS credentials and a lot of gear, a rare combination in the woods, you won't diddle around with SC injections, contraindications, or the like. Agreed, but that wasn't the concept of the original post, nor is it within the scope of this forum. I can't teach all the ins and outs of emergent wilderness care via an internet forum. I was only trying to give limited advice. You make good points, Anthony. Thanks for the discussion.
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galt
Nov 28, 2004, 11:59 PM
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DISCLAIMER: THIS IS STUPID! I DO NOT ADVOCATE YOU TAKING THIS ACTION. I AM NOT A Dr. I AM NOT A Nurse! I AM A PERSON WHO KNOWS A LITTLE BIT ABOUT HUMAN PHYSIOLOGY! That being said... I once ingested something that I was allergic to by accident. I didn't have epi nearby and was defiantly in a wilderness context. My throat started to close & I needed a quick way to get an anti-histamine into my system. Anyone ever chew tobacco? You guessed it. I crushed-up 75 milligrams of Benydrall (overdose, I know... but I'll deal with an overdose when I can breathe) & lined my gums with it. I almost puked (that would have been HORRIBLE), but I was able to keep it down. Sure enough the stuff hit my blood stream quicker then it would have from ingesting it... and I slept very well that night. I debated inhaling it (hey, it's the same premise coke users use right?) But decided that could really mess me up, so I lined my gums instead. So, if your scenario was ME!!! I'd hit myself with epi 1, take benydrall (probably 50 milligrams), hit myself with epi again, then stop joking around and line my gums with benydrall... and pray. Again, that's only if it were ME!!! I'm sure there are a million problems a Dr. could point out about doing it that way....
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sixleggedinsect
Nov 29, 2004, 12:14 AM
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In reply to: Epi Pens are not IM injections, but are actually SC injections (ever see the needle of an Epi Pen? Ain't long enough to go IM, unless you're overly famished and have ZERO body fat (even well conditioned athletes have a small degree of body fat... now whether they admit it or not is a different story!) it's been a couple years since ive played with expired pens, but i had thought the needle was long enough to get into the muscle at the side of the thigh. pinching my own thigh where instructed to adminster, it seems like it woudl definitely go into the muscle. the older kits, anakit and the like, also had needles that were long enough, i had thought, to go into the muscle of the shoulder where they were adminstered. (not much fat there on most folks). since the doses and instructions were the same for the devices, and they seem to be IM delivery, that might suggest the epipen is too. are you *sure* epi pens are SC delivery? see link, after a quick bit of browsing: http://tinyurl.com/4hws5. it suggests that epi pens are intended to be IM, allowing faster absorption than SC delivery.
In reply to: In reply to: but i do know that in the real world, if you have a life threatening reaction, you shoudlnt waste a second thinking about contraindications, and doctors will back me up on that. Perhaps true. Perhaps not. I know that I, as do many of my colleges, always take a moment (even if it is just a few seconds,) to think of the options. It's good medicine. Performing an intervention without considering the ramifications is a bad idea. right. you can continue to take a couple seconds to think about the ramifications becuase it will only take you a couple seconds. the rest of the lay public, the people who are reading this forum, will have absolutely nothing to think about except that a paramedic in a forum they read said they could do some damage by giving epi pen doses.
In reply to: Since I can not possibly teach someone all they need to know about Epi in a forum such as this I am relegated to giving some broad info, and imploring the reader to do more research, including having such a discussion with their physician. exactly. and the nutshell version, your 'broad' version, should not be "beware the contradindications'. it is 'give epi if it looks like they need it'. you know as well as i that asking that the reader do further research and discuss with physician will not make that happen. even if they did, the answer would be the same. normal rc.com readers who don't have prior training: if your patient, yourself, your partner, your neighbor, is having trouble breathing such that they can't talk without difficulty, and you believe it is caused by an allergic reaction, then give them a dose of epinephrine. that's how it works in the real world.
In reply to: You make good points, Anthony. Thanks for the discussion. thank you. i hope that wasn't your friendly way of opting out of said discussion and leaving me in the dark;). im still interested in your epi release calculation. how does one convert mol/L to mg? anthony
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reno
Nov 29, 2004, 2:30 AM
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In reply to: are you *sure* epi pens are SC delivery? Yep. I'm sure. The Epi Pens I've seen all say "to provide Subcutaneous injection of 0.3 mg Epinepherine, USP." or some variant of that.
In reply to: right. you can continue to take a couple seconds to think about the ramifications becuase it will only take you a couple seconds. the rest of the lay public, the people who are reading this forum, will have absolutely nothing to think about except that a paramedic in a forum they read said they could do some damage by giving epi pen doses. What I want people to understand is that Epi is not benign, and giving it can cause side effects. A recent article (I think it was a "Tech Tip" actually,) in either Climbing or R&I suggested that giving one self an Epi Pen injection was totally safe, and made no mention of any need for follow up care. So too do your suggestions. Perhaps you don't intend to, but that's the tone you give: "Epi is safe, and you don't need to consider the side effects." And THAT is what I call B.S. on.
In reply to: exactly. and the nutshell version, your 'broad' version, should not be "beware the contradindications'. it is 'give epi if it looks like they need it'. you know as well as i that asking that the reader do further research and discuss with physician will not make that happen. even if they did, the answer would be the same. normal rc.com readers who don't have prior training: if your patient, yourself, your partner, your neighbor, is having trouble breathing such that they can't talk without difficulty, and you believe it is caused by an allergic reaction, then give them a dose of epinephrine. that's how it works in the real world. I think we're gonna have to agree to disagree. In the real world, one needs to consider ALL aspects of any action. Doubly so when discussing medications. And to suggest that Epi can be given without worry is a grievous error, IMHO.
In reply to: You make good points, Anthony. Thanks for the discussion. thank you. i hope that wasn't your friendly way of opting out of said discussion and leaving me in the dark;). im still interested in your epi release calculation. how does one convert mol/L to mg? One can't simply convert. You'll need to know the molecular weight of the substance first. Chemistry class.
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sixleggedinsect
Nov 29, 2004, 3:09 AM
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In reply to: In reply to: are you *sure* epi pens are SC delivery? Yep. I'm sure. The Epi Pens I've seen all say "to provide Subcutaneous injection of 0.3 mg Epinepherine, USP." or some variant of that. ok. i pulled out an expired pen. from side of pen: "delivers 0.3mg intramuscular dose of epinephrine". unless Dey labs has changed something the manufacturer seems to agree with me.
In reply to: What I want people to understand is that Epi is not benign, and giving it can cause side effects. A recent article (I think it was a "Tech Tip" actually,) in either Climbing or R&I suggested that giving one self an Epi Pen injection was totally safe, and made no mention of any need for follow up care. So too do your suggestions. Perhaps you don't intend to, but that's the tone you give: "Epi is safe, and you don't need to consider the side effects." And THAT is what I call B.S. on. a good point. i never explicitly said that one should seek definitive care after dosing themselves, which is certainly necessary. but i dont think reading my posts would advise otherwise. i think you are twisting my criticism of your post because the standard protocol for laymen is not to consider contraindications, it is to administer to prevent death.
In reply to: [regarding converting mol/l into mg] One can't simply convert. You'll need to know the molecular weight of the substance first. Chemistry class. yeah, thanks. its been years since chemistry, so my own attempt at conversion obviously went spiraling out of control. by my napkin calculations, 4.0 pmol/dL/min works out to 7.3 x 10^-6 mg/dL/min. that is to say 0.0000073 mg/dL/min to your 1 mg/min. the units don't match up, and the scale is wildly off. i want to know the aforementioned rate of release of endogeneous epinephrine, and you quoted me a number, and i want to know where it came from. help me find where i went wrong in my obviously misled calculations. molecular weight of epi is 183.21 g/mol. anthony
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reno
Nov 29, 2004, 5:30 AM
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In reply to: In reply to: In reply to: are you *sure* epi pens are SC delivery? Yep. I'm sure. The Epi Pens I've seen all say "to provide Subcutaneous injection of 0.3 mg Epinepherine, USP." or some variant of that. ok. i pulled out an expired pen. from side of pen: "delivers 0.3mg intramuscular dose of epinephrine". unless Dey labs has changed something the manufacturer seems to agree with me. Mine says "Delivers 0.5 mg dose of Epinepherine via the subcutaneous route."
In reply to: In reply to: What I want people to understand is that Epi is not benign, and giving it can cause side effects. A recent article (I think it was a "Tech Tip" actually,) in either Climbing or R&I suggested that giving one self an Epi Pen injection was totally safe, and made no mention of any need for follow up care. So too do your suggestions. Perhaps you don't intend to, but that's the tone you give: "Epi is safe, and you don't need to consider the side effects." And THAT is what I call B.S. on. a good point. i never explicitly said that one should seek definitive care after dosing themselves, which is certainly necessary. but i dont think reading my posts would advise otherwise. i think you are twisting my criticism of your post because the standard protocol for laymen is not to consider contraindications, it is to administer to prevent death. Then I misunderstood your comments. But you're wrong here. The standard layman protocol (which, by itself, is an oxymoron, as the layperson has no protocol,) is to do nothing, and call 9-1-1. Anything else needs to be justified, and that justification needs to include good reasons to disregard any risks. Which is what you promote by saying that people should give Epi Pens with no regard to the consequences or exclusions. And that, sir, is where we differ. The rest is minor details.
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sixleggedinsect
Nov 29, 2004, 6:06 AM
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In reply to: In reply to: the standard protocol for laymen is not to consider contraindications, it is to administer to prevent death. Then I misunderstood your comments. But you're wrong here. The standard layman protocol (which, by itself, is an oxymoron, as the layperson has no protocol,) is to do nothing, and call 9-1-1. Anything else needs to be justified, and that justification needs to include good reasons to disregard any risks. Which is what you promote by saying that people should give Epi Pens with no regard to the consequences or exclusions. And that, sir, is where we differ. dude, wtf? first off, this entire conversation is in the context of wilderness medicine where the do nothing, call 911 bit is never the first thing that springs to mind. second, even in an urban environment, if someone is having a life threatening allergic reaction, ie anaphylaxis, then the layman course of action is TO GIVE THEM THE FRIGGIN' EPI-PEN ALREADY. fer goodness sakes, the reason they prescribe them in those idiot proof autoinjectors is so that the average joe simpleton can self administer this life saving medication (which coincidentally has NO contraindications given a life threat). unchecked by the voice of reason (and in this case, medical science), the layperson might read your post, and be confronted with the situation the OP described. they, worried about possible cardiac trouble, might spend a precious minute while their climbing partner breaks out into hives asking them whether they have a history of cardiac trouble. say the now wheezy climber, unable to speak in full sentences, tell them that yes, he had a heart attack four weeks ago and every person in his immediate family died before the age of 35 from massive MI, the layperson might hesitate yet further to administer epinephrine. possibly not give it at all. doctors, EMS professionals, the wilderness emergency medical schools across the nation, the manufacturers of the epipen itself, they all agree- there are no contraindications if there is a life threatening allergic reaction. now. you can, no doubt, sense im feeling a little snippy. i don't spend too much time hanging around rc.com, but every once in a while i pop on to ask a question, or troll the climbing forums. i saw your post going on about the dangers of epinephrine and took exception. it was inapprioriate in this forum, and wrong within context. i dont want to bang heads in a two person thread. ive got no bone with you, and im sure you're a competent medic, but good grief man, lay off the wilderness medicine advice. you've got some real credentials, and you wear them on your sleeve, and consequently the 316 viewers, at last count, take your advice to heart. with great power comes great responsability, or something like that. read up, think through anaphylaxis in the context of climbing, maybe take a wilderness emergency medicine course, and get back to us. most sincerely, anthony
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cbare
Nov 29, 2004, 9:41 AM
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Woah hold up there. We are starting to sound like a bunc of cranky internal med doc's. I think I can see validity in all of the points. Why don't we just sum it up for the poor guy who started this post. I think we all agree that the epi pen is absolutely indicated for anaphylaxis, and I think we all agree that we should watch for the side effects of epinephrine, ie elevated heart rate, increased myocardial oxygen demand, increased blood pressure, etc. In addition I think we all agree that you do not withhold the epi pen in an emergency even to a patient with heart problems, and that some one who has cardiac history (if we even know) should be watched carefully for the adverse effects of epinephrine. I think most improtantly all of the posts really prove that there are several options for some one to look at if they have anaphylaxis that is refractory to epinephrine. I believe that college dude was looking for information regarding additional options in the event you develop epinephrine refractory anaphylaxis, and hopefully he got it. Sorry about the typos it is 3 am and the ER is dead right now and boy am I tired. Thanks, cbare.
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reno
Nov 29, 2004, 1:45 PM
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In reply to: In reply to: In reply to: the standard protocol for laymen is not to consider contraindications, it is to administer to prevent death. Then I misunderstood your comments. But you're wrong here. The standard layman protocol (which, by itself, is an oxymoron, as the layperson has no protocol,) is to do nothing, and call 9-1-1. Anything else needs to be justified, and that justification needs to include good reasons to disregard any risks. Which is what you promote by saying that people should give Epi Pens with no regard to the consequences or exclusions. And that, sir, is where we differ. dude, wtf? first off, this entire conversation is in the context of wilderness medicine where the do nothing, call 911 bit is never the first thing that springs to mind. second, even in an urban environment, if someone is having a life threatening allergic reaction, ie anaphylaxis, then the layman course of action is TO GIVE THEM THE FRIGGIN' EPI-PEN ALREADY. fer goodness sakes, the reason they prescribe them in those idiot proof autoinjectors is so that the average joe simpleton can self administer this life saving medication (which coincidentally has NO contraindications given a life threat). *sigh* Once again... I'll say it for those that missed it. Epi Pens are helpful in life threatening situations involving anaphylactic reactions. BUT! They are not totally benign. There are risks. If you are planning on giving the Epi, you had better know what the risks are. Why is that not coming across?
In reply to: unchecked by the voice of reason (and in this case, medical science), the layperson might read your post, and be confronted with the situation the OP described. they, worried about possible cardiac trouble, might spend a precious minute while their climbing partner breaks out into hives asking them whether they have a history of cardiac trouble. say the now wheezy climber, unable to speak in full sentences, tell them that yes, he had a heart attack four weeks ago and every person in his immediate family died before the age of 35 from massive MI, the layperson might hesitate yet further to administer epinephrine. possibly not give it at all. doctors, EMS professionals, the wilderness emergency medical schools across the nation, the manufacturers of the epipen itself, they all agree- there are no contraindications if there is a life threatening allergic reaction. And unchecked by rational thought, one might read your post and give Epi Pens to anyone that got stung by a bee.... allergic reaction or not.
In reply to: now. you can, no doubt, sense im feeling a little snippy. No, really?
In reply to: i don't spend too much time hanging around rc.com, but every once in a while i pop on to ask a question, or troll the climbing forums. i saw your post going on about the dangers of epinephrine and took exception. it was inapprioriate in this forum, and wrong within context. i dont want to bang heads in a two person thread. ive got no bone with you, and im sure you're a competent medic, but good grief man, lay off the wilderness medicine advice. you've got some real credentials, and you wear them on your sleeve, and consequently the 316 viewers, at last count, take your advice to heart. with great power comes great responsability, or something like that.[/qyote] Since you mention it, what are YOUR credentials? Just curious, as you have made some decent arguments. Wondering if you're medically trained and educated, or just read a lot. In reply to: read up, think through anaphylaxis in the context of climbing, maybe take a wilderness emergency medicine course, and get back to us. LOL.
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sixleggedinsect
Nov 29, 2004, 3:46 PM
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In reply to: Since you mention it, what are YOUR credentials? Just curious, as you have made some decent arguments. Wondering if you're medically trained and educated, or just read a lot. i teach for one of the big wilderness med schools, but that doesn't matter. every WFR has been taught to say the same thing i'm a-sayin'. anthony (so, you gonna get back to me on the epi release stats, or did you realize you were off? i want that number for my classes)
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gullwing19
Nov 29, 2004, 5:04 PM
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There are ZERO contraindication when administering an Epi pen in a case of severe allergic reaction...such as a bee sting. ZERO.
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colkurtz
Nov 29, 2004, 5:22 PM
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This is a nice complement to the jackson falls thread. As I am only an amateur know-it-all, I will only ask questions. Could someone weigh in on Galt’s post? Is sublingual better under the tongue, or would the gums be just as good for quick dosage? Also, isn’t the nose even quicker? It seems to me that quick administration of benadryl is still an important topic, isn’t it? -Herr Doktor Kurtz
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flamer
Nov 29, 2004, 5:53 PM
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[quote="reno"] And unchecked by rational thought, one might read your post and give Epi Pens to anyone that got stung by a bee.... allergic reaction or not.
In reply to: read up, think through anaphylaxis in the context of climbing, maybe take a wilderness emergency medicine course, and get back to us. Just so you know reno knows what he's talking about, he has both the training and the experience. I've worked medical calls side by side with him as well as lot's of other medic's and I assure you he's one of the best. If you went by generic WFR logic you should give epi and benedryl to anyone who is stung by a bee. This is not always a good idea. In fact even as someone who IS allergic and has a prescription for Epi I would not use it everytime I get stung. IF I got stung and did not have a reaction(which is not only possible but has happened to me on 2 occasion's) I would not use my Epi. If i got stung and started showing signs of anaphlaxis i wouldn't hesitate to jam that bad boy in my thigh. The genaric qeustion to ask yourself(or the person your going to administer the shot too) is....Are you having a SEVERE(ie anaphalatic) allergic reaction??? josh
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shakylegs
Nov 29, 2004, 5:57 PM
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Perhaps it's a difference in laws, country-wise, but I thought regular folk weren't allowed to administer epi-pens, asthma breathers, etc, to other people. Unless, of course, you're accredited for that.
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sixleggedinsect
Nov 29, 2004, 6:11 PM
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In reply to: Perhaps it's a difference in laws, country-wise, but I thought regular folk weren't allowed to administer epi-pens, asthma breathers, etc, to other people. Unless, of course, you're accredited for that. first, find out if someone nearby does have some training. if they don't, do your best. samaritan law protects spontaneous rescuers who have their 'patient's best interest at heart.
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sixleggedinsect
Nov 29, 2004, 6:19 PM
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In reply to: If you went by generic WFR logic you should give epi and benedryl to anyone who is stung by a bee. This is not always a good idea. In fact even as someone who IS allergic and has a prescription for Epi I would not use it everytime I get stung. IF I got stung and did not have a reaction(which is not only possible but has happened to me on 2 occasion's) I would not use my Epi. If i got stung and started showing signs of anaphlaxis i wouldn't hesitate to jam that bad boy in my thigh. i call BS on the 'generic WFR logic' claim. have you taken a WFR? no teacher i have ever met tells students to fire away without symptoms of a life threat. the books are very clear too. (from the original post)
In reply to: We start heading down, and I feel the anaphylactic shock symptoms arising again this suggests that the OP knows that, and therefore indications for epinephrine is not the subject of this thread, whether or not to hold back is.
In reply to: There are ZERO contraindication when administering an Epi pen in a case of severe allergic reaction...such as a bee sting. ZERO. thank you. you said concisely what i've managed to drag out over 20 posts.
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flamer
Nov 29, 2004, 6:31 PM
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Mr. insect... Basically what you have drawn out over 20 post's(your words), is exactly what reno said in the first place.... he just went into more detail. He never said don't give epi to someone who needs it....but he did say don't give it to someone who doesn't....you are splitting hairs. josh
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reconbeef
Nov 29, 2004, 6:40 PM
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In reply to: If you went by generic WFR logic you should give epi and benedryl to anyone who is stung by a bee Where did this come from? I don't know of a serrious wilderness medical school that teaches this. I think the disconnect we're having here is that of street vs. wilderness protocals and ethics. I see this alot, on this and other forums. Boatertalk is the worst, there was a raging debate once on whether you could use a tube from a billage kit as an ET tube. It was good stuff. Anyway, the consensus, and it is a consensus, on treatment of anaphylaxis (not allergic reaction) in the backcountry is epinephrine (multi-dose vial or epi-pen) .3 mg IM, followed by 25-50mg of benadryl. More epi and benadryl as needed and evac. It's funny that this has turned into such a flame war, because in the WM world, this is a non-issue. They teach this from wilderness first aid all the way up to semester level wilderness medicine electives for medical students. I also think we're getting carried away with worrying about certifications and legal niceities. When I guided I carried an epi-pen 'illegally' in the sense that it wasn't mine, I didn't have a perscription, with the plan to use it on someone else. And you better believe I would have shot first and asked questions later if it came to that. If you don't want to get sued, let the poor bastard die and see what's in their pack. Otherwise, you run the (very small) risk of legal action. -James
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sixleggedinsect
Nov 29, 2004, 6:41 PM
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In reply to: Basically what you have drawn out over 20 post's(your words), is exactly what reno said in the first place.... he just went into more detail. He never said don't give epi to someone who needs it....but he did say don't give it to someone who doesn't....you are splitting hairs. that's not the way i see it, josh. ALS folk are trained differently than the rest of us. we operate on a minimal-info basis. basically- see ana? give epi. you paramedics, under certain circumstances, will give epinephrine before seeing late-stage violent reactions, and under those circumstances considering the contraindications is necessary and appropriate. but logging onto this forum and talking about contraindications is bogus- you are giving untrained folk the wrong impression. all the paramedics and the doctors and the like dont need you to tell them to consider the contraindications. if i had a nickel for every time i typed the word 'contraindications'... man, this is getting old. my fault, partially, for insisting that you guys tell it straight within the context of the original post and the forum.
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reno
Nov 29, 2004, 7:37 PM
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In reply to: I think the disconnect we're having here is that of street vs. wilderness protocals and ethics. No, the disconnect we're having is defining when Epi Pens need to be given. And it is my position, and has been from the start, that Epi Pens are beneficial in Immediate, Critical, Impending Doom, "Right the hell now or I'm gonna die!" anaphylactic reactions. I've also said, from the beginning, that while Epi is helpful, it can have side effects. In fact, let's look back at my very first post on this, just so we're clear:
In reply to: Now... As long as you meet the criteria below, you're *probably* safe taking two doses. Perhaps even three. But if I, as a paramedic, had a patient that needed more than 3 doses of Epi, I'd be thinking one of two things: This is the worst allergic reaction in the history of medicine, or this isn't an allergic reaction but something else that looks like an allergic reaction. http://www.rockclimbing.com/forums/viewtopic.php?t=76465&start=11 So... where in that whole post did I ever say that Epi shouldn't be given? If you can find a sentence, written by me, that says "Don't ever give Epi to the following people..." then I'll admit to being wrong, resign as a paramedic, and give up my first born child. What I said, is that certain criteria place you at greater risk with multiple doses of Epi. That's all. And if anyone want's to debate that, bring it on. Somehow, a person thinks I said otherwise. Not sure how the confusion started. Looking back, I think my words are clear. So... for the "Immediate, Critical, Impending Doom, "Right the hell now or I'm gonna die" reactions, then give the Epi. The thing is.... The actual frequency with which such cases happen is so rare, it defies numerical value. You ALWAYS have time to think. And for a "medical provider," especially one that purports to teach WFR/WEMT classes, to NOT acknowledge that taking a moment to think is a good thing, is quite simply scary. There is ALWAYS time to think.
In reply to: Anyway, the consensus, and it is a consensus, on treatment of anaphylaxis (not allergic reaction) in the backcountry is epinephrine (multi-dose vial or epi-pen) .3 mg IM, followed by 25-50mg of benadryl. More epi and benadryl as needed and evac. Yep. That's what I'm suggesting. Did so in the first post, in fact.
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sixleggedinsect
Nov 29, 2004, 7:57 PM
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In reply to: it is my position, and has been from the start, that Epi Pens are beneficial in Immediate, Critical, Impending Doom, "Right the hell now or I'm gonna die!" anaphylactic reactions. I've also said, from the beginning, that while Epi is helpful, it can have side effects. this is no longer a useful thread, but that's ok. me and you are probably the only ones still reading. as a final note, let's take that quote of yours. you followed it by saying "where in that whole post did I ever say that Epi shouldn't be given?"
In reply to: Now... As long as you meet the criteria below, you're *probably* safe taking two doses. well, look dude. you cant have it both ways. this quote suggests that there are times when you would not be safe taking two doses. your quote suggests that the times when you would not be safe were when you did not meet the criteria below, which was a long list of cardiac problems and irregularities. therefore, you are saying that epi shoudlnt be given, or at least sometimes shoudlnt be given, when people have cardiac issues. the context of this thread is a person who is experiencing anaphylaxis therefore you are advocating delaying, or not delivering at all, a life saving medication, and slapping a "i know what im talking about because im a medic" label on it. anthony
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reconbeef
Nov 29, 2004, 8:16 PM
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In reply to: You ALWAYS have time to think. And for a "medical provider," especially one that purports to teach WFR/WEMT classes, to NOT acknowledge that taking a moment to think is a good thing, is quite simply scary. First off, I fully understand what you saying about being cognizant of a drugs side effects/counter indications/ unintended consequences. However, as a paramedic and a wilderness medical instructor, I see the need to... well simplify. Education theory, and experiments have shown, that the average student leaves a class and retains 40-60% of what they are told. Sometimes 70% if Robin Williams is the teacher. I don't care how smart or on you are, or how good your instructor is, that's what you're taking away (often less). The majority of people that are taking these classes are not medical professionals, and never will be. Even most people who get their WEMT cert will never use it in the urban setting. So this leaves me with quesiton, what do I leave in, and what do I leave out. What is important for the river guide and the college outting leader to know about anaphylaxis? And man, those contra-inducations are not one of them. Because then they start freaking out when it's go time. Sure, you always have time to think. And you and I as paramedics have a deeper well to draw from. But for the average responder, they are lucky if they remember which end is up. Remember how easy your last CPR re-cert was? I don't know how old you are, but I remember a time when CPR was a 2 day, 12 hour course, with all these different ratios of odd numbers, 1:5, 3:1, square of 7: log of 9, ect. It was a nightmare. ACLS used to be the same way. And then AHA realized something intresting. People who were trained in CPR were not performing it in rescue situations, because they couldn't remeber the compression/ventilation rate, and were scared they would do it wrong. So AHA went back and simplified everything to denominators of 5 for the most part. And emphesized that doing something, even the wrong thing, was better than nothing. Here is what I (and I think Insect too) am saying; You have to be careful giving a lot of extraneous technical advice where it is not waranted. I could go into the complement system, the cascade of histamines and such (and do in WEMT courses) but for joe/joan climbing guide, all he/she needs to know is epi and benadryl for anaphylaxis. And again, professional wilderness medicine organizations, who have all been around for a long time and know of what they speak, all pretty much say the same thing. Not too much information, don't over simplify it, but give just what is needed. -James
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reno
Nov 29, 2004, 10:44 PM
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In reply to: In reply to: it is my position, and has been from the start, that Epi Pens are beneficial in Immediate, Critical, Impending Doom, "Right the hell now or I'm gonna die!" anaphylactic reactions. I've also said, from the beginning, that while Epi is helpful, it can have side effects. this is no longer a useful thread, but that's ok. me and you are probably the only ones still reading. Probably.
In reply to: as a final note, let's take that quote of yours. you followed it by saying "where in that whole post did I ever say that Epi shouldn't be given?" In reply to: Now... As long as you meet the criteria below, you're *probably* safe taking two doses. well, look dude. you cant have it both ways. this quote suggests that there are times when you would not be safe taking two doses. your quote suggests that the times when you would not be safe were when you did not meet the criteria below, which was a long list of cardiac problems and irregularities. therefore, you are saying that epi shoudlnt be given, or at least sometimes shoudlnt be given, when people have cardiac issues. the context of this thread is a person who is experiencing anaphylaxis therefore you are advocating delaying, or not delivering at all, a life saving medication, and slapping a "i know what im talking about because im a medic" label on it. Huh? You're telling me that by saying "this is probably safe," I actually mean "this is dangerous..."?? WTF? Anthony, you don't seem to hear what I'm saying. I don't know how I can say it more clearly: Giving an Epi Pen is the right thing to do for a life-threatening anaphylaxis reaction. Giving multiple doses of Epi to people with certain conditions can be dangerous. If you do give Epi to a victim, you should observe them for any changes, and evac as soon as possible. What part of that is unclear or misleading? Better yet... what part don't you agree with? Wouldn't you agree that Epi can cause side effects? Wouldn't you agree that people with certain conditions can be more susceptible to those side effects? Wouldn't you agree that if you're going to give an Epi Pen, then you should watch the victim closely -- as safety permits, of course -- for any changes? Don't you think that if someone is in extremis enough to warrant Epi, then they need evac? What part of my comments don't you get? Finally: What makes you think I'm gonna expose myself to legal liability by saying "This is always safe, and there is no risk, so do it" to members of this forum? My altruism doesn't extend that far. I try to offer helpful suggestions regarding medicine, but unlike yourself, I'm not taking an "always do this" approach to anything. Too much risk. But you already thought of that, right?
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reno
Nov 29, 2004, 10:50 PM
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In reply to: ... for joe/joan climbing guide, all he/she needs to know is epi and benadryl for anaphylaxis. And again, professional wilderness medicine organizations, who have all been around for a long time and know of what they speak, all pretty much say the same thing. Not too much information, don't over simplify it, but give just what is needed... Exactly what I believe. And if you're giving medications, you need to know what the risks are. Agreed?
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drector
Nov 29, 2004, 11:14 PM
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You guys blew it. Mostly the guy who keeps saying "yes, if the victim is gonna die then give him the shot" but then says "and be aware of all the medical mumbo-jumbo that can go wrong at that point." I for one will now let someone die before I give any kind of medication because you've scared me into thinking that anything I do will have consequences that, due to my ignorance, will be harmful. Gee, thanks. Dave
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reno
Nov 30, 2004, 12:04 AM
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In reply to: You guys blew it. Mostly the guy who keeps saying "yes, if the victim is gonna die then give him the shot" but then says "and be aware of all the medical mumbo-jumbo that can go wrong at that point." That would be me, right? How is providing you with information about a potential situation "blowing it?" If you take a trad leader class, and your instructor says "In a crack like this, place this piece of gear, but understand that there are various factors involved that might go wrong," how is that different? I've seen dozens of threads on this site about fall-factor physics... mostly theoretical expressions of what "might" happen. Funny how we'd rather talk complex theory regarding a fall, but do not want to discuss simple reality regarding an injury.
In reply to: I for one will now let someone die before I give any kind of medication because you've scared me into thinking that anything I do will have consequences that, due to my ignorance, will be harmful. Then you missed the point, and might find it difficult to find climbing partners. Look at it this way: You take a class, and in that class, someone tells you "Give the Epi Pen if your partner gets stung by a bee and has allergies to bee stings." You give the Epi Pen. Your partner doesn't get better. He dies. You feel like garbage. You vow to never climb again, because the anguish is more than you can bear. The problem is that your instructor never bothered to mention "Even though you give the Epi Pen, it doesn't always work. And there can be problems. So I'm going to prepare you to know why this can be." Had he done that, you'd understand that you did the right thing by giving the Epi, and that sometimes, to put it in the vernacular, "Shit happens." Does that clarify things? You're welcome.
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napoleon_in_rags
Nov 30, 2004, 12:20 AM
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Back to Shaky Legs.... I think there is no reason why you should not climb outside. You do need to make sure your partner(s) knows about your condition, knows where you keep the Epipens, knows how to escape a belay, and knows how to rescue you if you are incapacitated. You have to trust your belayer a little more than your avereage climber. I would be careful about climbing with some random schmuk from the gym at a crag you have never been to before. A climbing buddy of is deathly alergic to wasps and we talk it out every time before we rope up.
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napoleon_in_rags
Nov 30, 2004, 12:24 AM
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By the way - insect, Where do you teach WEMT - I was thinking about recerting by taking that.
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sixleggedinsect
Nov 30, 2004, 12:43 AM
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In reply to: By the way - insect, Where do you teach WEMT - I was thinking about recerting by taking that. I teach WFR/WFA for SOLO, most of whose courses are in new england. If that's not your area, WMA and WMI have plenty of courses in different parts of the country. are you doing WEMT instead of WFR for a reason? i see a lot of WEMT students who really wish they had done WFR instead. i wont talk you out of it. just want to make sure everyone makes the right decision. wait- you said recert. which course are you looking for? anthony
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karlbaba
Nov 30, 2004, 3:03 AM
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Interesting info So as long as we're on the subject, let's say we're in a wilderness setting any my partner gets stung and starts presenting symptoms of anaphylaxis. It's a suprise to her and thus she's not carrying an Epi pen (but I'm carrying benedryl) Is it worth trying to scare the crap out of her (or him?) and pack the gums and under the tongue with Benedryl? Is there a body position that would lessen the effects of Hypovolemia? Would putting on a pair of lycra tights make any difference? Naturally, it's better to do things properly, but whats the next best thing for the unprepared? Peace karl
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reno
Nov 30, 2004, 3:09 AM
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In reply to: Interesting info So as long as we're on the subject, let's say we're in a wilderness setting any my partner gets stung and starts presenting symptoms of anaphylaxis. It's a suprise to her and thus she's not carrying an Epi pen (but I'm carrying benedryl) Is it worth trying to scare the crap out of her (or him?) and pack the gums and under the tongue with Benedryl? Probably not worth the time to "scare the crap out of her," since she's most likely ALREADY scared (not being able to breathe is quite frightening, really.) The Benadryl is a great idea. Most adults do quite well with 50 mg of Benadryl (one or two capsules, depending on how it's packaged.)
In reply to: Is there a body position that would lessen the effects of Hypovolemia? Would putting on a pair of lycra tights make any difference? Flat on back, legs elevated, covered with a warm blanket or coat. Lycra is pointless.
In reply to: Naturally, it's better to do things properly, but whats the next best thing for the unprepared? The two best skills you can have for backcountry medical emergencies, IMHO, is 1) knowing when you need to find help ASAP and knowing when you have a little time or can continue, and 2) the ability to keep a cool head.
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ladylayback
Nov 30, 2004, 3:23 AM
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Immediately after using the 1st epi-pen take at least 50mg of oral benadryl, but I would take 100mg. The epi pen is fast acting and the bendryl is long lasting. The mechanism of action of each medication is slightly different. If you follow up with the benadryl you shouldn't continue to have the reaction. The benadryl is good for at least 2 hours, besides, you haven't used your second epi-pen yet. You should be able to get out and to a hospital without much problem. By the way, I'm a paramedic.
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reconbeef
Nov 30, 2004, 3:48 AM
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In reply to: Flat on back, legs elevated, covered with a warm blanket or coat. Lycra is pointless. Intresting article just came out on this, questioning the effictiveness of the legs up (Trendelenburg). Basically the study indicates that this maneuver fails to increase BP and/or cardiac output in most patients, does not improve tissue oxygenation, results in displacement of only 1.8% of total blood volume, and actually decreases cardiac output in the hypotensive patients. An additional study that compared T-berg positioning and leg raising in hypotensive patients concluded that any benefits of T-berg (higher MAP and cardiac output) were outweighed by adverse effects. We still teach it in wilderness medicine because, well, you don't have much else to work with. Just thought I'd pass it along, you can check out the full study if you want (sorry, no link). See: Myth: The Trendelenburg Position Improves Circulation in Cases of Shock Johnson S, et al. Can J Emerg Med 2004;6:48
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epic_ed
Nov 30, 2004, 4:47 AM
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In reply to: ... the rest of the lay public, the people who are reading this forum, will have absolutely nothing to think about except that a paramedic in a forum they read said they could do some damage by giving epi pen doses. FWIW, that's not how I took his post. In fact, I think you're making a big deal out of a little information that seems was included to simply cover his ass. I think most of us non-medical, thumbless idiots take exactly what is necessary and appropriate from Reno's original post -- that is, use multiple epi doses if necessary. I'm not sure why you have such a crab in your package about how he worded his message. Seems you're more interested in being "right" than you are in doing anyone a service by straightening out some periphrial information that might lead to some misconceptions by us average morons in "real life" situations. Ed
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alpnclmbr1
Nov 30, 2004, 5:14 AM
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Since it seems like I may get a good answer... What are the pro's and con's of using an asthma inhaler as a makeshift replacement for an epi-pen. Do you still follow the same procedure(as with an epi) with the benadryl in combination with the inhaler?
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karlbaba
Nov 30, 2004, 5:28 AM
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Thanks for the responses. Sounds like there are interesting questions about the position, which is significant since in a wilderness setting, (particularly rockclimbing) having somebody lie down and elevate their feet is sacrificing other opportunities. Any thoughts on ways to help keep (or force) the airway open while waiting for the Benedryl to take effect in the event of unexpected ana with somebody with no epi? PEace karl
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reconbeef
Nov 30, 2004, 5:44 AM
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In reply to: What are the pro's and con's of using an asthma inhaler as a makeshift replacement for an epi-pen. Epi-pens don't make very good pipes. Now Inhalers on the other hand... Ok, the other difference is that Epi-pens and Inhalers do totally different things. In a situation where you really needed an epi-pen (ie, you were seeing the light and feeling at peace), an inhaler would do as much good as above pipe. Actually, a pipe might do you more good in this case, go out with a bang and such. There really is no substitute for an epi-pen, which is why they are so wickedly expensive. The manufacturer (Lilly?) has a lock on an essential piece of medical equipment for a not insubstanital portion of the American public. Word on the street is that the old Ana-Kits are coming back, but I haven't seen any around in a while. If you really have a sensitivity to.... well anything, best bet is get a script from yer doc and carry it as an insurance kit. Plus, it's a nice little pick me up when you've been climbing for 22 hours, and you've still got 5 pitches left. -James
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cbare
Nov 30, 2004, 5:50 AM
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That is a great question alpnclmr1. First, you really need to give epinephrine as a front line drug in anaphylaxis. It is the only med that will reverse the life threatening problems associated with anaphylaxis. Then, you can start giving more defenitive therapies and there are a whole lot of them. Dont worry I will cover the what if all I have is an inhaler scenario in just a minute. In any event an inhaler may help depending on what is in the inhaler. Many inhalers have a steroid in them. Advair is a commonly used steriod inhaler. While steroids are helpful in anaphylaxis the usually take a while to start working, so a steriod inhaler would definatly not be in the primary treatment list. Other inhalers have a beta adronergic agonist in them. That is just a big word for something that mimics or activates a part of the nervous system that is responsible for the fight or fight response. ie. running away from a hungry tiger. Many of these inhalers contain a medication called albuterol or ventolin. Albuterol works bu acting on special recepters in the lungs and heart called beta receptors. Activation of beta receptors in the lungs (called beta 2 receptors) causes smooth muscles to relax and open up and hopefully allow more air in. You want this if you are having problems with airway swelling or spasm like in asthma or anaphylaxis. Becuase albuterol also acts on the heart, (beta 1 receptors) many people who take albuterol may develop a rapid pulse and sometimes elevations in blood pressure. Actually albuterol is chemically similar to epinephrine and acts in many similar ways. Sometimes you may hear someone say give him a bronchodilator. Albuterol is a prime example of a bronchodilator. Just a big word that means to open the bronchial passeges in the lungs. So, the answer to your question is both simple and complex. Let me say again, the epi pen should be the primary medication for treatment of anaphylaxis. However, if all you have is an albuterol inhaler I am not going to say don't use it because if thats all you got, then you may have to use it. Just like someone who posted earlier stated, he had a reaction and all he had was benadryl. He used it and he ended up living. Not ideal, but the wilderness is not an ideal environment. Sorry about being redundant, I just have to warn people about the dangers of using meds in a mannor that they are not typically used because I work in an environment where I have all the meds and resources at my disposal, but that is not the case in the styx. Typically people in anaphylaxis will get epinephrine, then an antihistamine like benadryl, then other therapies will be considered such as an albuterol treatment to help open the airway or some of the other therapies. I hope this helps answer your question. Again, sorry about all of the jargon it is more of cover my butt thing and a hope you understand things better thing. The basic answer is, if all you have is an inhaler you may have to use it. Thanks again, cbare.
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cjstudent
Nov 30, 2004, 6:06 AM
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In reply to: In reply to: What are the pro's and con's of using an asthma inhaler as a makeshift replacement for an epi-pen. Epi-pens don't make very good pipes. Now Inhalers on the other hand... Ok, the other difference is that Epi-pens and Inhalers do totally different things. In a situation where you really needed an epi-pen (ie, you were seeing the light and feeling at peace), an inhaler would do as much good as above pipe. Actually, a pipe might do you more good in this case, go out with a bang and such. There really is no substitute for an epi-pen, which is why they are so wickedly expensive. The manufacturer (Lilly?) has a lock on an essential piece of medical equipment for a not insubstanital portion of the American public. Word on the street is that the old Ana-Kits are coming back, but I haven't seen any around in a while. If you really have a sensitivity to.... well anything, best bet is get a script from yer doc and carry it as an insurance kit. Plus, it's a nice little pick me up when you've been climbing for 22 hours, and you've still got 5 pitches left. -James I carry epi ampules instead of the epi-pen. Sure for the person who has no training, the epi pen is pretty idiot proof. But for the WFR, or other trained individual, the epi ampules are a good (cost saving) alternative to the pens. Of couse u have to know the correct dosage, hence the need for the training. In NC, you can get certified to administer epi. Apparently the state has seen the light on the need for your average joe to know what epi is and how to use it since it is the front line drug in anaphalaxis. I have both the NC Epi cert along with my WFR. (and the fact that I'm a pharmacy tech but thats beside the point) And i didn't read all 5 pages of this thread. But for what its worth, I carry a very small first aid kit with me climbing multi-pitch routes. The thing only weights a few ounces, and is about 4x2x2". I carry 3 epi ampules in there (with syringes) and benadryl. That might not work for U but thats what I carry.
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reconbeef
Nov 30, 2004, 7:03 AM
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In reply to: But for the WFR, or other trained individual, the epi ampules are a good (cost saving) alternative to the pens. It's intresting, one wilderness medical school does instruct in multi-dose vials for their WFRs, but most teach epi-pens. The reason is that while the vials are no sweat for those of us who work routinely around medications, the bulk of those getting their WFRs are not in the medical field. I'm just not sold that you can cert someone in a week and 2 years later (while they are watching some fixin' to die) they get all the mechanics of drawing up medicine and injecting it right. "Wait, was that 3 or .3? I better give 30 just to be safe...."
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clausti
Nov 30, 2004, 7:44 AM
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edit: delete.
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sandbag
Nov 30, 2004, 8:01 AM
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In reply to: Just for s--- and giggles, say I'm allergic to Benadryll. I have a 'scrip for Atarax, in 10mg doses that I carry 'cause I'm allergic to spider bites and a bunch of other random s---. Never gone into anaphelectic shock, but did have to go to the ER and get some antihistamine shot into me and hook and IV up when I was at the beach once. Ok, I guess the point is, Anybody know if my Atarax is just as effective, in conjuction with the epinepherine, as Benadryl [they are different chemical forumas from what I can discover], if I *were* to have a severe allergic reaction? tru pill, not capsul with powder. thats a crappy allergy to have, is it really an allergy to Diphenhydramine, or is it a complication from other drugs you may be taking like MAOIs or other contrindicated meds?
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cbare
Nov 30, 2004, 1:03 PM
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Atarax or hydroxyzine and Benadryl or diphenhydramine share many similarities in the way the act. Both medications inhibit histamine and thus help with signs and symptoms of allergies. Benadryl acts by directly competing with histamine at the H1-receptor site. It binds to the receptor and does not allow histamine to activate the receptor. This mechanism is how we get the anti allergy effects. ie- drying of nasal membranes and other effects of benadryl. In addition, histamine receptors play a role in the brain and nervous system so you get other effects of benadryl ie fatigue & drowsiness. In addition benadryl has antiemetic ( anti nausea/vomiting) properties because of the whole histamine receptor thing. I do not really want to dive deep into the chemistry and prefer to keep it simple. Atarax acts in a similar way to benadryl, but atarax actually acts directly in the brain within it's subcortical areas (a big word that means below the cortex-the cortex is the upper brain where thinking, personality, and all that good stuff occurs--subcortical refers to the lower brain levels where the heart, blood vessel, sleep, and breathing centers are located) to cause antihistamine responses along with antinausea and anticholnergic responses. ( anticholnergic is a big word that describes blocking the neurotransmitter acetylcholine--in essence you can simply think of it as blocking the part of the nervous system that slows thing down and is responsible for nasal and airway secretions, salivation, gastric juice production and many other tasks---blocking acetylcholine will dry things up among other effects. Just to add a little more confusion benadryl has anticholnergic effects as well and yep H1 receptors play a role in that but I don't really want to take it any farther.) So now that your confused let me sum it up. Both medications act as antihistamines and act is both similar and different ways. Both meds will also cause drowsiness and other effects, but atarax usually makes people more sleepy. Atarax also has other uses for it's profound antinausea and sedation effects, ie to prevent nausea and vomiting during surgery, to help people with certain psychiatric disorders, and help with alcohol withdrawl. Sometimes atarax is a better antihistamine than benadryl and visa versa. This really depends on the individual person. If you cannot take benadryl, I think that atarax is an appropriate substitute. Just remember that there a multitude of antihistamines avaliable. ie chlorpheniramine (chlor tab) You may have problems with these as well, but at least there are options. The best thing to remember is that epinephrine is the standard for treating anaphylaxis, then we can worry about other treatments such as antihistamines. Hope this helped, cbare.
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cjstudent
Nov 30, 2004, 1:28 PM
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In reply to: In reply to: But for the WFR, or other trained individual, the epi ampules are a good (cost saving) alternative to the pens. It's intresting, one wilderness medical school does instruct in multi-dose vials for their WFRs, but most teach epi-pens. The reason is that while the vials are no sweat for those of us who work routinely around medications, the bulk of those getting their WFRs are not in the medical field. I'm just not sold that you can cert someone in a week and 2 years later (while they are watching some fixin' to die) they get all the mechanics of drawing up medicine and injecting it right. "Wait, was that 3 or .3? I better give 30 just to be safe...." I think my WFR class is different than most. I know most of them are quick week classes, but my WFR was taught through my university. So we didn't just get a weeks worth of class, I got a whole semester of classes along with weekends when we went out and did scenarios. And we spent alot of time on Epi....alot! But this is getting into an argument on ways to teach Epi and the different schools. I mean if u are dumb and can't remember if its 3, 30, or .3 you should write it down. Or even better buy a 3/10cc syringe. everyone seemed to throw there 2 cents worth in so i did...and thats why I also said "That may not work for YOU but thats what I carry"
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reno
Nov 30, 2004, 2:02 PM
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In reply to: Intresting article just came out on this, questioning the effictiveness of the legs up (Trendelenburg). See: Myth: The Trendelenburg Position Improves Circulation in Cases of Shock Johnson S, et al. Can J Emerg Med 2004;6:48 Yeah. I think there was another one in Ann. Emerg Med a couple months ago. My issues are all in boxes, and it's too darn early in the morning to start fighting with Med Line, but IIRC, they said the same thing.... "Doesn't do as much good as we once thought." But, as you mentioned, in the wilderness setting, we don't have much else, so you do what you can.
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reno
Nov 30, 2004, 2:10 PM
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In reply to: Since it seems like I may get a good answer... What are the pro's and con's of using an asthma inhaler as a makeshift replacement for an epi-pen. Do you still follow the same procedure(as with an epi) with the benadryl in combination with the inhaler? Dan: cbare gave a really good and detailed answer above. The one thing I didn't see him mention (I might have simply overlooked it,) is this: It is possible for the airway passages to be so constricted that an inhaler won't be effective (i.e. you can't inhale it deeply enough to get it where it needs to be... the alveolar/capillary membrane.) That's not saying it's a worthless or bad idea. Just that I'm not so sure it'll be all that effective. For what it is worth, Primatine Mist (the stuff you can buy at the pharmacy without a doctor prescription) is simply inhaled Epinepherine (the medication, not the 18 pitch route in RR.) ;) So... short version: Probably won't hurt, might help, worth a try, but don't get your hopes up.
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cbare
Nov 30, 2004, 3:46 PM
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In response to Reno. You are correct sir, I did fail to mention that inhaled meds are not really effective if the airway is swollen to the point of being unable to get medications deep enough to be of any benifit. This is why epinephrine is so important, It reverses the life threats. Then once you are somewhat stable and actually able to breath, you may consider bronchodilators and all of the other treatments for anaphylaxis. You are also correct about primatine mist. I totally forgot about the over the counter inhalers. Oh well insert foot in mouth. Thanks for the comment, cbare.
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alpnclmbr1
Nov 30, 2004, 4:07 PM
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Thanks a lot guys. This has to be one of the better threads of late.
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reconbeef
Nov 30, 2004, 4:21 PM
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In reply to: I mean if u are dumb and can't remember if its 3, 30, or .3 you should write it down. Or even better buy a 3/10cc syringe. Yea, that's easy to say in front of the computer with a cup of coffee and your bunny slippers (ok, that's what I'm wearing), but it's another ball game out in the sunny world. And again, people have different levels of training and experience. But if you have joe dirtbag raft guide (I love to pick on the boaters) who took his WFR over 2 years ago, and it's all kinda hazy and he's looking at a dying client and an amp of epi.... The beauty of the epi-pen is that it is totally fool proof. There is one way to screw it up; reverse directions. And I've seen that done, a woman I work with put it through her thumb. I had to moniter her BP (highish) for an hour and she was fine. She said it hurt like hell though. But there is no measuring, not drawing up, no trying to remember if you are going to give the wrong dosage of one of the most powerful cardiac drugs out there.
In reply to: everyone seemed to throw there 2 cents worth in so i did...and thats why I also said "That may not work for YOU but thats what I carry" No, no, I think it's intresting you bring this up. This is THE debate about epi in the outback, and it's a hot one. I think it's funny we spent so much time arguing style points, because this is the real bone of contention. Do you stick with the auto injector or do you give some 19 year old english lit major a needle and the big daddy of dangerous medicines and say, go gettem tiger! (You can see where I stand). -James
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addoil
Nov 30, 2004, 7:42 PM
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In reply to: Thanks a lot guys. This has to be one of the better threads of late. i hate this thread. reno is a mod. gave wrong info. covered his ass with the 'meet this criterea" crap. and bullied the buig who was correct. don't the only contraindication in a life or death situation is whether or not other people will get hurt. what he should have wrote is this. do it: but if you are not sure that the case is life threatening for what ever reason then realize that there are potential dangers. at best he never fully answered the question at worst he acted like a typical abusive mod never owning up to a simple mistake maybe some people should just suck it the feck up and say yes i didnt mean what i wrote exactly i should have written it better. istead of covering tracks by acting all condisending. epi is IM. there is not always time to think. that is why people train. to hard wire info. the only time you need to think is when there are multiple options. thats when contraindications come intop effect. and please people stop taking advice from EMTs. Reno is probably are extraordinarily well trained one. but still EMT's do not need much training. anyone worth his salt know that contraindications are a blanket statement. PEOPLE WHO KNOW DONT THINK THEY JUST DO....and dont even bother responding. your ego is way out of control. hell i live in Tajikistan i can see a boen head from here
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mtn_eagle
Nov 30, 2004, 11:12 PM
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In reply to: In reply to: Thanks a lot guys. This has to be one of the better threads of late. i hate this thread. I agree. This is a very complex issue that is best be left to experts with deeper, more fundamental knowledge of the topic. There's a whole lot more to anaphylaxis than epi and benadryl. Give me an hour and a blackboard and we could probably scratch the surface. As I stated in my first post, see an allergist if you want the best advice.
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reno
Nov 30, 2004, 11:33 PM
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In reply to: In reply to: i hate this thread. I agree. I'm terribly sorry you both feel this way. mtn_eagle, I agree with your comment about an allergist. In fact, I am fairly certain I mentioned something about an immunologist in one of my posts. addoil, I'm not sure what you've posted that contributed to this thread. You've not offered your input on the medical treatment side at all, actually. Please, if you think I gave bad advice, then I invite you to point out the bad advice (where did I go wrong,) and post your correct advice. Also, be certain to share your medical credentials, as you must obviously be a physician of some sort.
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epic_ed
Dec 1, 2004, 12:27 AM
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In reply to: In reply to: Thanks a lot guys. This has to be one of the better threads of late. i hate this thread. reno is a mod. gave wrong info. covered his ass with the 'meet this criterea" crap. and bullied the buig who was correct. Please explain where he was wrong. It has been debated to death about whether he included too much info, but it's never been disputed that he gave the wrong advice. As for being a mod -- we're allow to have opinions and we make mistakes from time to time just like you. I'm not sure what kind of freakin omniscient savior you're expecting to have as a moderator around here, but it ain't gonna happen. Feel free to step up to the plate and volunteer if you think you can do a better job. We'd love to share the work load with you, and they'll probably pay you double what their paying me. As for bullying -- again, show me an example of how Reno bullied anyone. His tone was clearly the more cordial and level headed between the two of 'em. Ed
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reconbeef
Dec 1, 2004, 12:53 AM
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In reply to: This is a very complex issue that is best be left to experts with deeper, more fundamental knowledge of the topic. There's a whole lot more to anaphylaxis than epi and benadryl But the problem is in a wilderness setting, that's all you have, and sometimes you're lucky to have that. I am not a physician (but I get yelled at by them sometimes), but I've put some time in in backcountry rescue and it makes the back an ambulance seem like a level one trauma center. I guess what really bothers me about this whole thread is the level of overcomplication. There are a lot of really smart medical people who climb who have been weighing in, but I'm not sure it helps the poor bastard who origionally posted:
In reply to: In reply to: I jab the first epi-pen into my thigh. That's good for about 15 minutes. We start heading down, and I feel the anaphylactic shock symptoms arising again. So I use up the second epi-pen, which is pretty much the limit of what you should take. So, now, am I screwed, or will the double doses of adrenaline be enough for me to get me out of there? For arguments' sake, I also have some Benadryl with me. This is a pretty simple question, assuming anaphylactic shock. You've got the benadryl, got the epi, and I think the importance of the benadryl as the end solution (rather than the temporary soluiton that the epi-pen offers) has been well addressed. I railed on this topic in the wilderness first aid post about a month ago. You are dealing with a very limited scope of options. Even from a liscensed perspective, as a medic on a mountain rescue team, I get to do all sorts of crazy s*it on rescue situations that would get me hung in the street because the wilderness protocals kick in. Doing medicine in the backcountry is closer to a nursing situation that it is to your typical EMT/Paramedic experience. To sum up, I think that there is a wilderness specific frame of reference that a lot of really smart, really well trained people lack. And I know because before I started doing wilderness medicine, I lacked it too. So realize that your training and experience will not allways translate over to a wilderness scenario. As a final note, get involved. I guarantee wherever you are, if you'e climbing, there is a SAR or mountain rescue team close to you. It's lots of fun, you get to play in the woods, and if you have a medical background you get to do some good stuff. Plus, if you join a technical team, you will learn more about rigging and ropes than you ever thought possible. This is a good place to start: http://www.nasar.org/nasar/links.php Just trying to keep the thread positive. -James
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karlbaba
Dec 1, 2004, 1:00 AM
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I think it's a huge mistake for anyone to claim that it's inappropriate for us to discuss how to treat ana in a wilderness setting. The vast majority of climbers aren't going to deeply investigate the minutia of this subject in an academic setting, so what happens when somebody gets stung by a bee 10 miles from the road? Do I pull out a disclaimer form that says "Only medical doctors should be empowered to treat medical conditions that might be serious and life threatening. You are therefore advised to immediately proceed to a medical facility, or unable to do so, wait for qualified, on-duty personnel to reach you. In the event that these procedures fail, only an ordained clergy member is authorized to....... Sheesh Karl
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cjstudent
Dec 1, 2004, 1:07 AM
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In reply to: In reply to: Thanks a lot guys. This has to be one of the better threads of late. and please people stop taking advice from EMTs. Reno is probably are extraordinarily well trained one. but still EMT's do not need much training. anyone worth his salt know that contraindications are a blanket statement. PEOPLE WHO KNOW DONT THINK THEY JUST DO....and dont even bother responding. your ego is way out of control. Who are you? How about going back and reading alittle bit. I think Reno has given pretty good info, just as everyone else has. To me, reading this post it seems to be more of a conflict of getting a "second medical opinion". There are several qualified people who have responded to this thread. Reno for one isn't just an EMT, if you would read, he's a paramedic which (at least from my side of the country) is quiet a bit of training. So are some of the other responders, WFR instructors or paramedics. And your last statement is a pile of shiz. People who know don't think they just do. ???? Yea if you lived by that idea, you would kill your patient for sure. Doctors know alot of shiz, and they think about possibilities, not just do stuff.
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cjstudent
Dec 1, 2004, 1:15 AM
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In reply to: In reply to: I mean if u are dumb and can't remember if its 3, 30, or .3 you should write it down. Or even better buy a 3/10cc syringe. Yea, that's easy to say in front of the computer with a cup of coffee and your bunny slippers (ok, that's what I'm wearing), but it's another ball game out in the sunny world. And again, people have different levels of training and experience. But if you have joe dirtbag raft guide (I love to pick on the boaters) who took his WFR over 2 years ago, and it's all kinda hazy and he's looking at a dying client and an amp of epi.... The beauty of the epi-pen is that it is totally fool proof. There is one way to screw it up; reverse directions. And I've seen that done, a woman I work with put it through her thumb. I had to moniter her BP (highish) for an hour and she was fine. She said it hurt like hell though. But there is no measuring, not drawing up, no trying to remember if you are going to give the wrong dosage of one of the most powerful cardiac drugs out there. In reply to: everyone seemed to throw there 2 cents worth in so i did...and thats why I also said "That may not work for YOU but thats what I carry" No, no, I think it's intresting you bring this up. This is THE debate about epi in the outback, and it's a hot one. I think it's funny we spent so much time arguing style points, because this is the real bone of contention. Do you stick with the auto injector or do you give some 19 year old english lit major a needle and the big daddy of dangerous medicines and say, go gettem tiger! (You can see where I stand). -James Ok I agree with you on alot of that. Maybe its just me, I am trying to be the guy who knows enough to be useful, but isn't a doctor. You know? For me I think the ampules are the way to go. I've been pretty interested in wilderness medicine every since my first day of WFR, and intend on getting my EMT within the year so i can be a WEMT. (and join our rescue squad) Thinking back to my WFR class, there are some people in there who need the epi pen with pictures. :D And as a WFR instructor i could see where u would be leary about teaching ampules. I would say, that for you, it would depend on your class and students. We went over both epi pens and ampules in my wfr class. i think most of the students in my class decided to go with the epi-pens over ampules. I'd like to think I'm someone who has their head screwed on straight and in the moment of an emergency would be calm and think back to training instead of "uhhh, dude, stab them with an epi pen" and as far as in NC, i have a certification that says i can use epi on other people in the absence of a doctor. (or if the doc is there, if he tells me to do it) hopefully that would help me with some legality issues
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climbingnurse
Dec 1, 2004, 1:25 AM
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OK, first, a lot of people have been bashing Reno. I don't think any of them have the knowledge or experience that he does. (Please note that the nurses and doctors on the forum have not contradicted anything he said.) I don't think he said anything that was misleading and I am fairly certain he didn't say anything that was wrong. If I go into anaphylaxis, I want him there. Failing that, I'd be psyched to have someone nearby following his advice. Anyway, a lot of people have mentioned the shortcomings of epi-pins. I see them having two major drawbacks: expense and short shelf-life. The obvious advantage is that they are virtually idiot proof. (Unless you put it through your thumb...) So anyway, the outdoor ed folks at my school recently came up with an alternative. (Please don't read what I'm about to write if you are a safety nazi hell-bent on demonstrating your self-righteous indignation towards people who do things differently than you.) We made anaphylaxis kits that consist of: -3 0.3 mL syringes (with fixed needles) -3 ampules containing 1 mg of epi in 1 mL of solution -A bunch of benadryl -3 alcohol swabs -3 2" x2" gauze pads -directions for use AND (this is key) we started an annual training program that is mandatory for all guides. This class and the kits were designed by myself with the help of one of my professors who has more medical credentials than anyone should and is also a backpacker. The 0.3 mL syringes are also key as it makes it pretty hard to overdose someone. These kits cost about $20 (for at least three doses of Epi) and expire every 18 months instead of every 8 or whatever for Epi-pins. Some final advice: Be very wary of people who give their opinions while trying to withold as much information as possible about their own backgrounds. (And just to make sure everyone knows, as I stated in my first post in this thread, I am not a nurse yet. I still have one semester to go.)
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reconbeef
Dec 1, 2004, 1:46 AM
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In reply to: AND (this is key) we started an annual training program that is mandatory for all guides. This is TOTALLY the key. I agree that on the face of it, the ampules are the way to go, you can multi-dose, they are smaller, lighter, cheeper. And if your outting club/guide service/keg party has an instituted program for training and quality assurance, then it's a winner. From a once every three years WFA or WFR class, it's a little dicier. I would love to make people re-cert their WFRs every year, but it's not economically possible. It used to be every two years, and then one of the big schools, to be different, switched to three years, so everyone had to grudgingly follow suit. When I have taught the multi-dose epi, I make people do 5 to 10 wind sprints, and then do the draw up. Because you're going to be so freaked out, shaking, and trying to remember what the hell it was your instructor said. This is why, despite the cost of and pain in the ass of the epi-pen, they are the perfered alternative for most people/programs. But good on you guys for taking the initative to up together a epi program, that's pretty progressive. -James
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cbare
Dec 1, 2004, 2:01 AM
Post #87 of 108
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I think this has been a worth wile forum. People from many clinical disiplins has weighed in and have given many unique options that people can put in their back country tool box. I am not shure what some people qualify as an expert in anaphylaxis. I suppose an immune specialist, but I don't think you need an advanced degree in medicine or biological science to have a solid working knowledge of this subject. I think a paramedic is certanly qualified to talk about anaphylaxis. Perhaps people are not aware of the extent of their training. In the USA most paramedics undergo a rigorous training program that consists of several hundred class and clinical lab hours, in addition they usually undergo a clinical rotation that exceeds 1000 hours. They rotate through ER, ambulance internship, womans health, surgery, intensive care, and pediatrics. In addition, they must have documented patient contacts and have proof of skills use. ie, must have several documented medications deliveries,(typically they can administer 50 or more meds) and special skills such as intubation. Finally they go through a grueling exam that puts them in stressful scenarios where they must demonstrate all of their skills by the book. ie, trauma management, medical management,(anaphylaxis is a commonly tested medical problem) advanced cardiac management, airway stations, iv stations and medication delivery, this is followed by a board style paper exam. All in all pretty complex training. Most paramedic programs are associate degree programs and require college level biology, anatomy and physiology, math, and english classes as prerequisits to the core medic program. Heck even an EMT Basic recieves over 100 hours of training and must pass a similar exam and complete a clinical rotation. This post is a deviation from the original thread but I know allot of people have a he's just an ambulance driver attitude and hopefully this will help people better understand paramedics. After all I think these forums are more about learning than a competition of the minds. Take care everybody , cbare.
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cbare
Dec 1, 2004, 2:03 AM
Post #88 of 108
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Registered: Sep 18, 2004
Posts: 64
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I think this has been a worth wile forum. People from many clinical disiplins has weighed in and have given many unique options that people can put in their back country tool box. I am not shure what some people qualify as an expert in anaphylaxis. I suppose an immune specialist, but I don't think you need an advanced degree in medicine or biological science to have a solid working knowledge of this subject. I think a paramedic is certanly qualified to talk about anaphylaxis. Perhaps people are not aware of the extent of their training. In the USA most paramedics undergo a rigorous training program that consists of several hundred class and clinical lab hours, in addition they usually undergo a clinical rotation that exceeds 1000 hours. They rotate through ER, ambulance internship, womans health, surgery, intensive care, and pediatrics. In addition, they must have documented patient contacts and have proof of skills use. ie, must have several documented medications deliveries,(typically they can administer 50 or more meds) and special skills such as intubation. Finally they go through a grueling exam that puts them in stressful scenarios where they must demonstrate all of their skills by the book. ie, trauma management, medical management,(anaphylaxis is a commonly tested medical problem) advanced cardiac management, airway stations, iv stations and medication delivery, this is followed by a board style paper exam. All in all pretty complex training. Most paramedic programs are associate degree programs and require college level biology, anatomy and physiology, math, and english classes as prerequisits to the core medic program. Heck even an EMT Basic recieves over 100 hours of training and must pass a similar exam and complete a clinical rotation. This post is a deviation from the original thread but I know allot of people have a he's just an ambulance driver attitude and hopefully this will help people better understand paramedics. After all I think these forums are more about learning than a competition of the minds. Take care everybody , cbare.
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epic_ed
Dec 1, 2004, 2:07 AM
Post #89 of 108
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I don't know how anyone can say this hasn't been a good, informative thread. Personally, I've learned a lot and it's been one of the more appropriate, on-topic discussions we've had about wilderness medical crisis. Thanks to all of you who have contributed to the exchange of ideas. Ed
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reno
Dec 1, 2004, 2:52 AM
Post #90 of 108
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In reply to: We made anaphylaxis kits that consist of: -3 0.3 mL syringes (with fixed needles) -3 ampules containing 1 mg of epi in 1 mL of solution -A bunch of benadryl -3 alcohol swabs -3 2" x2" gauze pads -directions for use AND (this is key) we started an annual training program that is mandatory for all guides. I think this is one hell of a great idea, and in my opinion, it should be the national standard for wilderness training. If I can support it in any way... any way at all... please tell me. Teach the right things, then teach them again every year, just to keep folks current. As a medical professional, I applaud this approach. Bravo, sir. Bravo indeed.
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reno
Dec 1, 2004, 3:02 AM
Post #91 of 108
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In reply to: When I have taught the multi-dose epi, I make people do 5 to 10 wind sprints, and then do the draw up. Because you're going to be so freaked out, shaking, and trying to remember what the hell it was your instructor said. This is why, despite the cost of and pain in the ass of the epi-pen, they are the perfered alternative for most people/programs. James: I like this! Can I borrow that idea? :twisted: I once hit on the idea, while training tactical medics, to light a string of firecrackers behind them when they were trying to start an IV line. Sure, it caused a lot of blown veins at first, but darned if they weren't the best in the state with an IV needle after I was done. :)
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reconbeef
Dec 1, 2004, 3:24 AM
Post #92 of 108
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In reply to: it should be the national standard for wilderness training And therein lies the rub. There IS no national standard for wilderness training, and this is somthing that everyone on this thread (well everyone in general, but I'm realistic) should realize. If you take an American Red Cross first aid course or American Heart Association CPR course in Maine, it will be the exact same course that you would get in Nevada. It is a national standard, to which all other courses are held. No (to my knowledge) CPR courses are being offered that don't confirm to the AHA guidelines. Not so with wilderness medicine. As I said, there is no national certifying body. Reno, you could hang out a shingle tommorow and open Reno's wilderness medicine boutique and start teaching you students trepanation and to cric anyone who got stung with a bee. And you could do it. At least until some guy shows up at your door with a hole in his head and his neck wanting a few words. Case in point, there is a guy in DC who runs a (fairly lucrative) wilderness first aid school that doesn't have the first damn idea what he's doing, and it's caused some real problems. I can't believe the guy hasn't been sued, but he keeps on doing his thing. This is why I advise people to a) take a class from one of the big three or barring that b) make sure you know who it is that is teaching your class. The closest we have in the States to a 'standard setter' is the Wilderness Medical Society (www.wms.org). The publish a set of wilderness guidelines (which is well worth having) but do not endorse a standard, and most likely never will. So it's sort of everyone for themselves. The cirricula of the big three schools are pretty much the same, except for a few style points, but they are in agreement on the big issues (holes in head: bad). So this is why you won't get a standard. And, to repeat something I've said here before, multi-dose epi is a bad idea for 90% of those taking these classes and performing medicine in the outback. Climbingnurse is in an institution that has decided to put time and money towards maintaing this standard (with an MD to oversee it). But most people coming to get their cert aren't. They show up once every three years to recert, and man, some of them are just there to punch the clock and get their card. You can tell they are going to forget everything the next day. While having their drawbacks, Epi-Pens are the safest option for lay providers. I'm actually waiting for the first camper to die after being coded out by too much epi and see how long these amp programs stay around. I just think there's too much to go wrong, and epi-pens work great. They've saved thousands of lives. Can't argue with that. -James
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reconbeef
Dec 1, 2004, 3:26 AM
Post #93 of 108
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In reply to: I once hit on the idea, while training tactical medics, to light a string of firecrackers behind them when they were trying to start an IV line. Sure, it caused a lot of blown veins at first, but darned if they weren't the best in the state with an IV needle after I was done. Now that's a good one. I always thought they should teach professional CPR courses in poorly lit public rest rooms. Seems like that's where you always end up doing it. -James
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cjstudent
Dec 1, 2004, 3:34 AM
Post #94 of 108
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Registered: Oct 21, 2003
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In reply to: In reply to: it should be the national standard for wilderness training And therein lies the rub. There IS no national standard for wilderness training, and this is somthing that everyone on this thread (well everyone in general, but I'm realistic) should realize. If you take an American Red Cross first aid course or American Heart Association CPR course in Maine, it will be the exact same course that you would get in Nevada. It is a national standard, to which all other courses are held. No (to my knowledge) CPR courses are being offered that don't confirm to the AHA guidelines. Not so with wilderness medicine. As I said, there is no national certifying body. Reno, you could hang out a shingle tommorow and open Reno's wilderness medicine boutique and start teaching you students trepanation and to cric anyone who got stung with a bee. And you could do it. At least until some guy shows up at your door with a hole in his head and his neck wanting a few words. Case in point, there is a guy in DC who runs a (fairly lucrative) wilderness first aid school that doesn't have the first damn idea what he's doing, and it's caused some real problems. I can't believe the guy hasn't been sued, but he keeps on doing his thing. This is why I advise people to a) take a class from one of the big three or barring that b) make sure you know who it is that is teaching your class. The closest we have in the States to a 'standard setter' is the Wilderness Medical Society (www.wms.org). The publish a set of wilderness guidelines (which is well worth having) but do not endorse a standard, and most likely never will. So it's sort of everyone for themselves. The cirricula of the big three schools are pretty much the same, except for a few style points, but they are in agreement on the big issues (holes in head: bad). So this is why you won't get a standard. And, to repeat something I've said here before, multi-dose epi is a bad idea for 90% of those taking these classes and performing medicine in the outback. Climbingnurse is in an institution that has decided to put time and money towards maintaing this standard (with an MD to oversee it). But most people coming to get their cert aren't. They show up once every three years to recert, and man, some of them are just there to punch the clock and get their card. You can tell they are going to forget everything the next day. While having their drawbacks, Epi-Pens are the safest option for lay providers. I'm actually waiting for the first camper to die after being coded out by too much epi and see how long these amp programs stay around. I just think there's too much to go wrong, and epi-pens work great. They've saved thousands of lives. Can't argue with that. -James I would also agree to say that, its very important that people get their WFR from one of the Big Three schools. WMA, WMI, or SOLO. Since also the closest thing you can get to a standard is found in those three schools. Not joe-schmoe's wilderness medicine "school"
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reno
Dec 1, 2004, 3:44 AM
Post #95 of 108
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Registered: Oct 30, 2001
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In reply to: I would also agree to say that, its very important that people get their WFR from one of the Big Three schools. WMA, WMI, or SOLO. Since also the closest thing you can get to a standard is found in those three schools. Not joe-schmoe's wilderness medicine "school" Yep. I mention these schools in the I&A FAQ, which can be found HERE.
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climbingnurse
Dec 1, 2004, 12:53 PM
Post #96 of 108
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In reply to: In reply to: Reno quotes keith's earlier post about the epi kits and mandatory training. I think this is one hell of a great idea, and in my opinion, it should be the national standard for wilderness training. If I can support it in any way... any way at all... please tell me. Teach the right things, then teach them again every year, just to keep folks current. As a medical professional, I applaud this approach. Bravo, sir. Bravo indeed. I think this approach is most appropriate for school outing clubs. They make up a significant portion of the clientelle for the "big 3". It would be great if all outing clubs were encouraged to take this approach. It's not too hard to implement. Spread the word...
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climbingnurse
Dec 1, 2004, 12:55 PM
Post #97 of 108
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In reply to: In reply to: When I have taught the multi-dose epi, I make people do 5 to 10 wind sprints, and then do the draw up. Because you're going to be so freaked out, shaking, and trying to remember what the hell it was your instructor said. This is why, despite the cost of and pain in the ass of the epi-pen, they are the perfered alternative for most people/programs. James: I like this! Can I borrow that idea? :twisted: I once hit on the idea, while training tactical medics, to light a string of firecrackers behind them when they were trying to start an IV line. Sure, it caused a lot of blown veins at first, but darned if they weren't the best in the state with an IV needle after I was done. :) James, you are mean. Reno, you are evil.
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climbingnurse
Dec 1, 2004, 12:56 PM
Post #98 of 108
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In reply to: Case in point, there is a guy in DC who runs a (fairly lucrative) wilderness first aid school that doesn't have the first damn idea what he's doing, and it's caused some real problems. Just wanted to state for the record that I'm not that guy. :shock:
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climbingnurse
Dec 1, 2004, 1:01 PM
Post #99 of 108
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In reply to: Climbingnurse is in an institution that has decided to put time and money towards maintaing this standard (with an MD to oversee it). Keith's biggest pet peeve: People who assume that only a doctor could do this sort of thing. The person who helped me develop the kits and the training program is NOT an MD. She is a Family Nurse Practitioner (amongst other fancy initials including PhD). I, for one, see this as being a much more appropriate role for a nurse than for a doctor. Nurses get more training in education and tend to be better at seeing the big picture in patient care settings. I know you meant no harm, but you just inadvertently trampled on my career field.
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tgmd
Dec 1, 2004, 3:07 PM
Post #100 of 108
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Registered: Oct 8, 2004
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Interesting thread, at least from my perspective (Emergency physician). I respectfully disagree with climbing nurse about doctors. I enjoy wilderness settings and climbing, so I have some experience. I don't have the experience in the field as does Reno and others here. I can only treat the ones the medics save in the field. But, please, some of us doctors are pretty good at teaching and enjoy it. Some of us do get "the big picture" and understand the difficulties of wilderness field medicine. I don't believe that I am an exception. I have met a lot of very qualified professionals, doctors, nurses, and EMS personnel, at Wilderness Medicine Society meetings. I hope that your expeiences are more positive in the future.
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climbingnurse
Dec 1, 2004, 3:33 PM
Post #101 of 108
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Didn't mean to bash Docs, tgmd. Just trying to point out to people what the typical roles are in healthcare for doctors vs. nurses. I still think that, in general, nurses are more trained for education and looking at the whole person/situation. That's not to say that some doctors haven't learned to do those things quite well.
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tgmd
Dec 1, 2004, 4:23 PM
Post #102 of 108
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Climbing nurse- My wife is a Family Nurse Practitioner and is the best educator I have ever encountered. There is a big difference between the roles of an RN and a NP. Nurses that work in the ED, on the hospital floors, OR, or Recovery as a general rule have little experience teaching other providers and aren't given enough time to teach patients. As you complete your training and work full-time, I think you will see a big difference between nurses in your program and nurses who work outside of a teaching institution. Although this thread was about epi and wilderness settings, I will close by saying that I want folks here to work with folks like you who want to educate, take classes and learn about how to help their climbing partners in emergency situations. Please don't generalize about what doctors and nurses are until you have worked in the field. I think you will be surprised. By the way, take the Epi-Pen if you think its a life or death situation, take the Benedryl immediately, get off the rock and call for help, and consider seeing an allergist/immunologist for discussion of allergy testing and de-sensitization therapy. Good luck!
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mtn_eagle
Dec 1, 2004, 5:08 PM
Post #103 of 108
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In reply to: I'm terribly sorry you both feel this way. mtn_eagle, I agree with your comment about an allergist. In fact, I am fairly certain I mentioned something about an immunologist in one of my posts. addoil, I'm not sure what you've posted that contributed to this thread. You've not offered your input on the medical treatment side at all, actually. Please, if you think I gave bad advice, then I invite you to point out the bad advice (where did I go wrong,) and post your correct advice. Also, be certain to share your medical credentials, as you must obviously be a physician of some sort. Trained in internal medicine and subsequently sub-specialized in critical care, pulmonary and sleep medicine. I worked as an ER doc for 2 years in an academic level 1 trauma center where I was an ACLS instructor for medical students and house staff. I taught and rode with paramedics on a regular basis and was the voice on the radio when they asked "Doc, this isn't working...what should we do now?" I was a hospitalist for a while working in an open ICU when I realised I didn't have enough training and went back for 3 more fellowships. I've given televised lectures concerning high altitude medicine. I recently signed with a private practice group in CO. As for NP's, my wife in an NP working for a heart failure/transplant group. She is incredible at her job and her patients love her. Her NP training was broad and the cardiologists frequently turn to her concerning vaginal discharges, rashes and other non-heart issues that they are clueless about, but she doesn't pretend to be a cardiologist and frequently runs things by them to make sure she's doing the right thing. Even though she worked in an ER for 5 years, she'd still defer questions about anaphylactic shock to me. If you asked her, she'd tell you to go to PA school rather than NP school because the programs are designed by doctors and tend to be more hard science rather than theory. But to each his own.
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brundige
Dec 1, 2004, 6:12 PM
Post #104 of 108
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In reply to: reconbeef wrote: Quote: it should be the national standard for wilderness training And therein lies the rub. There IS no national standard for wilderness training, and this is somthing that everyone on this thread (well everyone in general, but I'm realistic) should realize. If you take an American Red Cross first aid course or American Heart Association CPR course in Maine, it will be the exact same course that you would get in Nevada. It is a national standard, to which all other courses are held. No (to my knowledge) CPR courses are being offered that don't confirm to the AHA guidelines. Not so with wilderness medicine. As I said, there is no national certifying body. Reno, you could hang out a shingle tommorow and open Reno's wilderness medicine boutique and start teaching you students trepanation and to cric anyone who got stung with a bee. And you could do it. At least until some guy shows up at your door with a hole in his head and his neck wanting a few words. Case in point, there is a guy in DC who runs a (fairly lucrative) wilderness first aid school that doesn't have the first damn idea what he's doing, and it's caused some real problems. I can't believe the guy hasn't been sued, but he keeps on doing his thing. This is why I advise people to a) take a class from one of the big three or barring that b) make sure you know who it is that is teaching your class. The closest we have in the States to a 'standard setter' is the Wilderness Medical Society (www.wms.org). The publish a set of wilderness guidelines (which is well worth having) but do not endorse a standard, and most likely never will. So it's sort of everyone for themselves. The cirricula of the big three schools are pretty much the same, except for a few style points, but they are in agreement on the big issues (holes in head: bad). So this is why you won't get a standard. And, to repeat something I've said here before, multi-dose epi is a bad idea for 90% of those taking these classes and performing medicine in the outback. Climbingnurse is in an institution that has decided to put time and money towards maintaing this standard (with an MD to oversee it). But most people coming to get their cert aren't. They show up once every three years to recert, and man, some of them are just there to punch the clock and get their card. You can tell they are going to forget everything the next day. While having their drawbacks, Epi-Pens are the safest option for lay providers. I'm actually waiting for the first camper to die after being coded out by too much epi and see how long these amp programs stay around. I just think there's too much to go wrong, and epi-pens work great. They've saved thousands of lives. Can't argue with that. -James I would also agree to say that, its very important that people get their WFR from one of the Big Three schools. WMA, WMI, or SOLO. Since also the closest thing you can get to a standard is found in those three schools. Not joe-schmoe's wilderness medicine "school" _________________ if your interested in wilderness medicne consider courses taht fufill state requirements for the subject matter and then add onto it bt including the wilderss aspects of it FOr instance WFR .make shure that you are certified by the state as a first respoder those courses usually have a set standard as you have to pass exit exams . the same goes for WEMT , wich fufills EMT-B requiremensts in 45 states
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karlbaba
Dec 1, 2004, 7:33 PM
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I've done an EMT and a few years later a WFR. Now my certs have expired. Even though I tended to score "at the top of my class', I'd like to agree that this stuff leaks from your head pretty fast if you aren't in the rescue and patch biz. The more idiot proof things can be made the better. Maybe this stuff will come back into my brain in a pinch, maybe not. Even if I don't recert, I'd like to make a point of reviewing my material each season PEace Karl
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reno
Dec 1, 2004, 7:40 PM
Post #106 of 108
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In reply to: I'd like to agree that this stuff leaks from your head pretty fast if you aren't in the rescue and patch biz. Karl: It leaks pretty fast even if you ARE in the "Body and Fender Repair" business. I still look things up to double check myself on certain things. Some of the things are so common and "routine" that it's not needed, but some things are so infrequent that a little refresher is helpful. Good thread, everyone. Thanks for participating. (No, I'm not locking the thread ... just remembered I wanted to say "thanks" to everyone, so figured I'd do it now.)
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napoleon_in_rags
Dec 1, 2004, 10:55 PM
Post #107 of 108
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In reply to: are you doing WEMT instead of WFR for a reason? i see a lot of WEMT students who really wish they had done WFR instead. i wont talk you out of it. just want to make sure everyone makes the right decision. wait- you said recert. which course are you looking for? anthony I am on the National Registry EMT - I am curious to the "W" perspective in WEMT. And I believe that will maintain my qual for another year. Maybe I am wrong.
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cjstudent
Dec 2, 2004, 1:21 AM
Post #108 of 108
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In reply to: In reply to: are you doing WEMT instead of WFR for a reason? i see a lot of WEMT students who really wish they had done WFR instead. i wont talk you out of it. just want to make sure everyone makes the right decision. wait- you said recert. which course are you looking for? anthony I am on the National Registry EMT - I am curious to the "W" perspective in WEMT. And I believe that will maintain my qual for another year. Maybe I am wrong. Well the W part of WEMT is to give you the wilderness aspect. Also the W stands for the WFR, because i think the courses are the same. You would be learning how to deal with emergencies in the backcountry, away from definitive care. Improvised traction splints, spinal injuries, having to bivy, navigation, doing evacs, common injuries in the wilderness like sprains and strains, and how to properly splint broken bones (w/o commercial splints), and it addresses illnesses found in the back country like high altitude pulminary adema, acute mountain sickness, dehydration, heat stroke...etc etc etc. you also deal with anaphalyxis which is what got this started. Above is just some of the topics covered. I think you are right about that qualifying for the recert for EMT. I did it the other way, I have my WFR now and am enrolling for EMT basic next semester.
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