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Partner j_ung


Nov 28, 2004, 2:32 PM
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If you want a 100% safe climbing experience, crack open a beer and watch Masters of Stone VXII.

I don't think you know what you're talking about. I went crossed eyed and got a headache from MOS III. 100% safe, indeed.

:P


sixleggedinsect


Nov 28, 2004, 2:46 PM
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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


reno


Nov 28, 2004, 3:15 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.


galt


Nov 28, 2004, 3:59 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....


sixleggedinsect


Nov 28, 2004, 4:14 PM
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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


reno


Nov 28, 2004, 6:30 PM
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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.


sixleggedinsect


Nov 28, 2004, 7:09 PM
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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


reno


Nov 28, 2004, 9:30 PM
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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.


sixleggedinsect


Nov 28, 2004, 10:06 PM
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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


cbare


Nov 29, 2004, 1:41 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.


reno


Nov 29, 2004, 5:45 AM
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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.


sixleggedinsect


Nov 29, 2004, 7:46 AM
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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)


gullwing19


Nov 29, 2004, 9:04 AM
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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.


colkurtz


Nov 29, 2004, 9:22 AM
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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 Galtís post? Is sublingual better under the tongue, or would the gums be just as good for quick dosage? Also, isnít the nose even quicker?

It seems to me that quick administration of benadryl is still an important topic, isnít it?

-Herr Doktor Kurtz


flamer


Nov 29, 2004, 9:53 AM
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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


shakylegs


Nov 29, 2004, 9:57 AM
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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.


sixleggedinsect


Nov 29, 2004, 10:11 AM
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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.

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.


sixleggedinsect


Nov 29, 2004, 10:19 AM
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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.


flamer


Nov 29, 2004, 10:31 AM
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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


reconbeef


Nov 29, 2004, 10:40 AM
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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


sixleggedinsect


Nov 29, 2004, 10:41 AM
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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.


reno


Nov 29, 2004, 11:37 AM
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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.


sixleggedinsect


Nov 29, 2004, 11:57 AM
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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


reconbeef


Nov 29, 2004, 12:16 PM
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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


reno


Nov 29, 2004, 2:44 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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