Need to vent and process this

[jess11RN]

At the tail end of my day today , I got a call from a teacher who was sending student up to my office thinking student was having an allergic reaction.

Student has full body hives, no further symptoms. I try to call mom, no answer. Get my AP, take vitals, think for a minute, still can't get ahold of mom, decide to give stock epi.

Paramedics arrive and question why I gave stock epi and why they were called-in front of the student!!!! Emergency contact arrives (still can't get ahold of mom) and they subtly try to convince them to refuse transport to the ER. What?!?! Of course, by the time emergency contact asks for transport (thank goodness), paramedic looks at student and hives have dissipated, redness still present (thanks epi!). Tells emergency contact that it wasn't hives, probably just a rash. I KNOW it was hives.

I cannot believe this just happened!

Regardless of what the paramedic had to say, I know that I did the right thing. And to add, I am so incredibly thankful that the teacher noticed this and called me right away and so thankful that admin and the secretaries were there to help and have my back.

3 more days until break.

[R5RN, BSN, RN, EMT-P]

First, as a paramedic myself, I apologize on behalf of the *ahem* jerk of a paramedic you dealt with. It's so frustrating that there are still quarrels between RNs and paramedics (speaking on the paramedic's unprofessional behavior towards you).

My background is EMS and ED nursing, and I have done many lectures on the proper use of epinephrine. One of the things I really harp on is giving epi early. I use the explanation that epi is for anaphylaxis and I try to explain that anaphylaxis and anaphylactic shock are two different things. You want to give epi at the anaphylaxis point so it doesn't BECOME anaphylactic shock. I have witnessed a paramedic coworker of mine opt not to give epi to my sister, who was experiencing anaphylaxis albeit not shock. In my area, we have been focused for the past few years on really trying to lower the threshold for giving epi.

With that, I'd like to say, when in doubt, give epinephrine. And it sounds like you did just that. However, for educational purposes, it sounds like your patient did not necessarily meet the criteria for requiring epi. I do think it is important to understand when to give and when not to give epinephrine (again, I still stand by when in doubt, give it... and that paramedic should feel the same and not be rude to you about that), but the definition of anaphylaxis is when one or more of the following is met:

1. Acute onset of an illness (minutes to several hours), with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips/tongue/uvula), and at least 1 of the following: (1) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia) or (2) reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence); OR

2. Two or more of the following that occur suddenly after exposure to a likely allergen for that patient (minutes to several hours): (1) involvement of the skin/mucosal tissue (eg, generalized urticaria, itch/flush, swollen lips/tongue/uvula), (2) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia), (3) reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence), or (4) persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting); OR

3. Reduced blood pressure after exposure to a known allergen for that patient (minutes to several hours): (1) for infants and children, low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure, and (2) for teenagers and adults, systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person's baseline.

Source

Remember, there are many reasons someone may develop hives that are not going to lead to anaphylaxis. If there are no other systems involved (e.g. hives with respiratory, cardiac, GI, etc. involvement), it may not be anaphylaxis. I'm a big proponent of self-reflection after situations like this, and it gives an opportunity to improve our practice. It helps to boost our confidence the next time we are faced with something similar. Take some time to research epinephrine administration and anaphylaxis/allergic reactions. And again, I apologize for the lack of professional courtesy from EMS.

[CanIcallmymom, BSN, RN]

Remember, there are many reasons someone may develop hives that are not going to lead to anaphylaxis. If there are no other systems involved (e.g. hives with respiratory, cardiac, GI, etc. involvement), it may not be anaphylaxis. I'm a big proponent of self-reflection after situations like this, and it gives an opportunity to improve our practice. It helps to boost our confidence the next time we are faced with something similar. Take some time to research epinephrine administration and anaphylaxis/allergic reactions. And again, I apologize for the lack of professional courtesy from EMS.

Great info! And you are on point with self-reflection.

[Estateboy, RN, EMT-P]

Being on both sides of the fence, I've had the "God complex" attitude from ER nurses directed at me personally. They lighten up when I tell them I'm also a Med-Serg RN but that attitude can come anyone. It doesn't matter the profession... bad attitude is bad attitude.

[jess11RN]

First, as a paramedic myself, I apologize on behalf of the *ahem* jerk of a paramedic you dealt with. It's so frustrating that there are still quarrels between RNs and paramedics (speaking on the paramedic's unprofessional behavior towards you).

My background is EMS and ED nursing, and I have done many lectures on the proper use of epinephrine. One of the things I really harp on is giving epi early. I use the explanation that epi is for anaphylaxis and I try to explain that anaphylaxis and anaphylactic shock are two different things. You want to give epi at the anaphylaxis point so it doesn't BECOME anaphylactic shock. I have witnessed a paramedic coworker of mine opt not to give epi to my sister, who was experiencing anaphylaxis albeit not shock. In my area, we have been focused for the past few years on really trying to lower the threshold for giving epi.

With that, I'd like to say, when in doubt, give epinephrine. And it sounds like you did just that. However, for educational purposes, it sounds like your patient did not necessarily meet the criteria for requiring epi. I do think it is important to understand when to give and when not to give epinephrine (again, I still stand by when in doubt, give it... and that paramedic should feel the same and not be rude to you about that), but the definition of anaphylaxis is when one or more of the following is met:

1. Acute onset of an illness (minutes to several hours), with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips/tongue/uvula), and at least 1 of the following: (1) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia) or (2) reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence); OR

2. Two or more of the following that occur suddenly after exposure to a likely allergen for that patient (minutes to several hours): (1) involvement of the skin/mucosal tissue (eg, generalized urticaria, itch/flush, swollen lips/tongue/uvula), (2) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia), (3) reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence), or (4) persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting); OR

3. Reduced blood pressure after exposure to a known allergen for that patient (minutes to several hours): (1) for infants and children, low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure, and (2) for teenagers and adults, systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person's baseline.

Source

Remember, there are many reasons someone may develop hives that are not going to lead to anaphylaxis. If there are no other systems involved (e.g. hives with respiratory, cardiac, GI, etc. involvement), it may not be anaphylaxis. I'm a big proponent of self-reflection after situations like this, and it gives an opportunity to improve our practice. It helps to boost our confidence the next time we are faced with something similar. Take some time to research epinephrine administration and anaphylaxis/allergic reactions. And again, I apologize for the lack of professional courtesy from EMS.

I completely agree with self-reflection and further research. I do that with many situations and I agree that it does help make me a better nurse!

FARE and ACAAI both recommend giving epinephrine with generalized hives.

"Epinephrine should be used immediately if you experience severe symptoms such as shortness of breath, repetitive coughing, weak pulse, generalized hives, tightness in the throat, trouble breathing/swallowing, or a combination of symptoms from different body areas such as hives, rashes, or swelling on the skin coupled with vomiting, diarrhea, or abdominal pain. Repeated doses of epinephrine may be necessary."

Epinephrine Auto Injector | Symptoms & Treatment | ACAAI Public Website

I understand fully what you are saying regarding the definition of anaphylaxis and when epinephrine would be definitively warranted. I also understand that hives can be caused by a multitude of reasons. But, when these national organizations support the administration of epi in the community with hives, when both organizations campaigns are "when in doubt, give epi." What are we (as school nurses within the community) to do when things are questionable, other than give epi? It's a tough situation to be in, unfortunately. Especially being in the school when we are the only medical personnel armed with nothing but a stethoscope, pulse ox, stock epi (if we're lucky), and a phone to call 911 if we are in need of additional medical supports.

[kidzcare]

I completely agree with self-reflection and further research. I do that with many situations and I agree that it does help make me a better nurse!

FARE and ACAAI both recommend giving epinephrine with generalized hives.

It is better to give epi not knowing if the hives would've cleared up on their own than to not give and the unthinkable happen. These kiddos are in our care and we need to make the split second decisions (ALONE! EMTs travel at least in pairs).

[RatherBHiking, BSN, RN]

Why do the paramedics have a right to tell a nurse a patient doesn't need transport? That's scary. They aren't trained nearly as much as we are. I called them for a teacher who was having a very low pulse and blood pressure who was so dizzy she couldn't walk down the stairs, let alone drive to the dr or hospital. I called and they took my report and their good old time. They didn't feel it was an emergency, more of a transport. I was just worried she was going to crash on me. They ended up admitting her for a couple days. Anytime someone gets an epi pen they need to go to the ER because we all know the epi doesn't last very long. I just don't understand why the paramedics were questioning that. Well good job to you for looking out for your student and not taking chances!!!!

[ruby_jane, BSN, RN]

I love R5RN's post - thank you for being gracious and your thoughts and well-documented data!

Here's the thing: Nowhere in my policy does it say I can use my open script EpiPens (courteously provided by Kaleo) on a student without known anaphylaxis.

However: I have nursing judgement. Would I stand by and watch a student with a "reaction consistent in appearance with anaphylaxis" worsen IF I had something with which to treat the student? Unlikely. It's my nursing judgement versus the appearance of "prescribing" (according to the BON). I figure I can justify my nursing judgement better than I can justify a dead kid.

EMT's don't have nursing judgment. They have a bunch of P&P and a medical director on speed dial but a lot of what we do is based on our nursing judgement, which is based on our training and lived experiences.

[R5RN, BSN, RN, EMT-P]

I completely agree with self-reflection and further research. I do that with many situations and I agree that it does help make me a better nurse!

FARE and ACAAI both recommend giving epinephrine with generalized hives.

"Epinephrine should be used immediately if you experience severe symptoms such as shortness of breath, repetitive coughing, weak pulse, generalized hives, tightness in the throat, trouble breathing/swallowing, or a combination of symptoms from different body areas such as hives, rashes, or swelling on the skin coupled with vomiting, diarrhea, or abdominal pain. Repeated doses of epinephrine may be necessary."

Epinephrine Auto Injector | Symptoms & Treatment | ACAAI Public Website

I understand fully what you are saying regarding the definition of anaphylaxis and when epinephrine would be definitively warranted. I also understand that hives can be caused by a multitude of reasons. But, when these national organizations support the administration of epi in the community with hives, when both organizations campaigns are "when in doubt, give epi." What are we (as school nurses within the community) to do when things are questionable, other than give epi? It's a tough situation to be in, unfortunately. Especially being in the school when we are the only medical personnel armed with nothing but a stethoscope, pulse ox, stock epi (if we're lucky), and a phone to call 911 if we are in need of additional medical supports.

Oh absolutely! Your role as a school nurse definitely varies from those in EMS. For example, in my state, our protocols would not warrant epinephrine in the way that you described your student (again, please know that I am NOT suggesting that you erroneously gave epinephrine, and I am a FIRM supporter of when in doubt, give it, regardless of whether you're a nurse or a paramedic).

Just another interesting view that I totally see where you're coming from and the recommendations by FARE and ACAAI, but the paramedics may use a different source to determine their criteria for giving epi. Regardless, it sounds like you were very calm and made the right decision!

And while this next comment is not addressing you or anything you've said, I've seen posts since mine that are still proving that "quarreling" between paramedics and nurses. As both a paramedic and a nurse, I shake my head every time I hear someone on either side of the fence try to argue who has more education, is smarter, is more trained, has more capabilities, etc. These are two very separate jobs with different focuses. It's important to consider the reality the other person has in their position, and not put each other down because of assumptions of the other persons chosen profession.

[NRSKarenRN, BSN, RN]

30 yrs ago I worked for my kids Pediatrician at her summer camp for 9 week session; 2 days a week I left for 12hrs to visit my homecare patients in Philadelphia returning at 7PM at night.

Got report at 705PM that known asthmatic camper was stung by a bee in morning, wheezed and they gave her a neb treatment x2. Took one look at her, saw chalk WHITE hands, listened to lungs--almost silent. Immediately gave 50MG Benadryl, epipen and paged Pediatrician STAT to infirmary--of course they were off-site at movie theater 30 min away. Other RN hadn't realized delayed anaphylaxis.

Peds Dr pissed as child's Mom on staff, who heard that child in infirmary (PM sick call kids told her) and Mom came running down. Given orders for Prednisone 60Mg, albuterolTX q 3 hrs, steroid inhaler --up all night watching child. Survived without problems.

Yes, always give Epinephrine for suspected allergy reaction.

[3ringnursing, BSN]

it was not until 2014 (when I began working my present job in telephone triage) that I learned EMS had the autonomy to chose NOT to transport a patient to the ER for whom assistance had been called (even if the patient wants to go).

Say what???

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Incidently, in 1995 a patient on our unit (the mother of one of our CNA's) became unresponsive around 0030 - as charge nurse for the unit I called a code.

We were actually a separate entity from the hospital we were occupying the two upper floors of, which was a DO specialty hospital and on it's last "legs" prior to closure of the facility.

When the code team for this hospital arrived to our floor in the patient's room the team provider asked me WHY I had called a code? After all the patient still had spontaneous breathing and heart rate.

Gee I don't know, but it seemed prudent to do so for a suddenly unresponsive patient whom had been AAO x 4 only minutes previously ... this patient never regained consciousness, and didn't live long enough to last to the end of the shift.

The patient's daughter was naturally devastated when she discovered her mom had passed away so suddenly - and it had happened on MY watch (although this wasn't actually technically my patient, I figured they were ALL my patient's when I am charge nurse).

I have no regrets to this day about calling that code, and I know you were right to call EMS for your student too. The only regrets I might have had pertaining to that night would have arisen from had I NOT chosen to request immediate help at all. It doesn't take long for a previously responsive patient to circle the drain and code - I don't think waiting for a lack of spontaneous breathing and HR is appropriate, especially if your nurse "spidey sense" has already flared.

Good job nurse!

[pedi_nurse]

I would say all who questioned, need a lesson on biphasic reactions.

It's not even like its a rare thing... 20%. SMH

[pedi_nurse]

FARE and ACAAI both recommend giving epinephrine with generalized hives.

"Epinephrine should be used immediately if you experience severe symptoms such as shortness of breath, repetitive coughing, weak pulse, generalized hives, tightness in the throat, trouble breathing/swallowing, or a combination of symptoms from different body areas such as hives, rashes, or swelling on the skin coupled with vomiting, diarrhea, or abdominal pain. Repeated doses of epinephrine may be necessary."

This is interesting. I've had generalized hives before... it was a slowish progression over a couple of hours to the point they were all over (and HUGE). I had to get steriod shots to get them to go away, since round the clock benadryl wasn't working.

I've always been under the assumption that one symptom that indicates a compromise in the ABCs, or the combo of two other symptoms, such as hives and vomiting. It's good to know that generalized hives required a more urgent approach.

The only time I've given epi, I had to sit around and wait a few minutes for his symptoms to get worse (previously no known allergy teen). It started as mild facial swelling, which I gave benadryl for, but it progessed to vomiting. My epi was expired and I had no standing order for it (thanks so much, terrible nursing director) so I didn't feel comfortable giving it until there was verbal permission from a parent OR until there was clear indication of ABC compromise (kids vitals were perfect, no problem talking, swallowing, breathing, no cough/scratchy throat). Fortunately grandmother walked in as I had called the parent before his vomiting started and so they were already heading over. EMS didn't seem like they wanted to transport. Granted, they did hang around for a half hour before saying as much, but they had a policy with their department that you have to transport any kid who has received epi.

The only negative interaction I've had with EMS was calling for resp issues with a non asthmatic. The kid was sating 95% for the better part of an hour and lungs sounded SO junky and tight. He looked miserable as well. First EMS guy thought he sounded fine and of course when they got here he was reading 97%. I listened to him again when a couple of them went out to the rig leaving just 1 or 2 in here.... the kid sounded "good" because he was so tight. They half assed albuterol to appease me, letting him do five minutes of treatment until they asked if it was helping. The kid said no, so they stopped. I was so pissed. My acute care experience is in pediatric pulmonology, I know lungs. Kid ended up being sent to the ER by his pediatrician and was diagnosed with pneumonia and bronchitis. Albuterol absolutely would have brought him relief, and denying it put the kid at risk for worsening resp distress.