School nurse delays giving epi pen

MrNurse(x2), ADN · Sep 20, 2016

I realize we have not heard the nurses side to this story but if a student presents to me saying they need their epi pen, they get the epi pen. There would never be a reason to not give it.

We are assuming this student is being entirely transparent in her recollection. I tend to listen to the professional first, as they are less apt to be distorted by emotion, than the principals in the story; mom and daughter. I do the same when it is my kids and a teacher, not just nurses.

nursetlm, ADN · Sep 20, 2016

I agree. Half of my kids don't know their last name, let alone their allergies, so I will always defer to doctor's orders/nursing judgement. But, I have 5 and 6 year olds.

KatieMI, BSN, MSN, RN · Sep 20, 2016

Not a school nurse but a severe allergy sufferer here, and...

1). parents were totally uninformed about what allergy is and what it implies. It is questionable to use antihistamine before or after EpiPen if there is no symptoms at all ("I just thought that I might eat something contaminated") or only minor symptoms (rash and itching, NOT in perioral area, no SOB, perioral edema, etc) but antihistamines are integral part of treatments. They are not "masking" anything, they just slow things down and can entirely stop less severe reactions. It doesn't mean that patient will not go in anaphylaxis right after taking antihistamine - after all, the drug needs time to act. But it very well might buy some time. And, providing that antihistamines work slow, they actually should be given before adrenaline and steroids, if it is possible.

I participate in support group for people living with severe allergies and saw and heard more times that I can count that "EpiPen is a first-line treatment for allergy". The truth is, adrenaline has nothing at all to do with allergy process. It only treats symptoms of anaphylaxis, the most severe form of immediate allergic reaction type I, and with some quite serious risks at that. Same about nebulizers, they treat only airway spasm when it happens. Things that treat allergy itself are antihistamines, steroids, cromoglycate, omalizumab, immunosupression, BMT, after all - but not adrenaline or IV fluids.

2). Course of every single one allergic reaction is not predictable even when patient had multiple severe reactions upon the same exposure.

3). A 15 y/o should be old enough to learn to ask about every single thing, every single time. Parents after so many years should be wise enough to believe no one but themselves reg. mass food production.

The Powers that over there can, of course, mandate shooting Epi first move after any pertinent complain. But there soon be other kid rushed in ER with symptomatic SVTs or dangerous BP elevation, and another concerned mom crying out to "review policies and protocols". The nurse in question absolutely must call 911, and the student must go to ER even upon suspicion of possibility of reaction. But to shoot Epi after she was able to walk to the office and without any assessment signifying systemic symptoms would be useless at the best - and it would not prevent "late anaphylaxis" happening couple of hours after.

P.S. "no harm company" about shooting adrenaline almost for prophylaxis was, and is, lavishly paid of by Mylan Pharma, which is now up to its neck in hot water due to price gouging, as most people here know. Same goes about pushing EpiPen as a "first line defense" for everyone from parents to providers. Adrenaline sure is an effective drug, but is is also definitely not a "safe" one. Adult patients with severe allergies, especially those over age 40 and suffering from elevated BP, currently have to be heavily re-educated about NOT grabbing Epipen unless they have systemic symptoms, lest they risk very high chance of deadly arrythmias, hemorrhagic strokes and so forth.

I wonder how much out of approximately $400 Mylan Pharma got from each pack went toward wining and dining everybody who might be responsible for "plans and policies" featuring EpiPen as a Pavlovian dog response, assessment and common logic be d***ed.

tining, BSN, RN · Sep 20, 2016

If the parent states Epi pen FIRST, then why did she supply Benadryl???????

The blow by blow description sounds like this all took place in less than 5 minutes. Kid comes in requesting epi, nurse offers Benadryl, student refuses, call made to mom, epi given, and 911 called.

kidzcare · Sep 20, 2016

If the parent states Epi pen FIRST, then why did she supply Benadryl???????
The blow by blow description sounds like this all took place in less than 5 minutes. Kid comes in requesting epi, nurse offers Benadryl, student refuses, call made to mom, epi given, and 911 called.

Minutes mean a lot in terms of respiratory distress.

Good point on the Benadryl.

JenTheSchoolRN, BSN, RN · Sep 20, 2016

We revised our allergy action plan. Benadryl for possible exposure (not confirmed) with zero symptoms or contact with substance and itchy rash/hive presentation.

Any other symptom than skin presentation - straight to Epi.

But my school went entirely peanut and nut free because with no cafeteria and kid eating in classroom, peanut and nut oil can be hard to ensure is cleaned properly. It helps, except when students ignore that, bring in peanut butter, eat next to kid with a peanut allergy, and kid is in my office with an itchy mouth/throat 20 minutes later. (I went straight to Epi & 911 on that one. Outcome was very good.)

If a student has a history of anaphylaxis with an action plan from her doctor that says Epi first, I'm going Epi first, 911, than calling the parent to meet us at the hospital. That is the part of the story that baffles me a bit. Is there a missing piece?

allnurses Guide · Sep 20, 2016

What is dangerous about following the emergency plan upon assessment? If a student came to me, telling me they had ingested an allergen and their plan and doctor's orders were to give Benadryl first, that is what I would do, unless their sx were indicative of anaphylaxis, OR, they were telling me they needed the Epi over the Benadryl. Actions need to be based on the assessment and the situation. I have one student with multiple, multiple, multiple food allergies. Some require Epi, some require Atarax. Each situation is different.

It is dangerous because these orders are not the protocol anymore and many docs have missed that memo.

http://www.stlallergy.com/pdfs/Child..._Allergies.pdf
...There are several KEY POINTS that need to be fully understood and have changed the way experts now approach food allergy patients since new Food Allergy Guidelines were published in the fall of 2010. Not all Emergency physicians or ambulance EMTs, doctors or nurses are yet aware of these changes in the updated Guidelines.
If there has been a suspected INGESTION of a food to which your child is allergic and any body-wide (systemic) symptoms occur, Epi Pen or Epi Pen Jr should be given immediately without hesitation and then you should call 9-1-1!
Benadryl is no longer recommended for allergic reactions due to food allergy INGESTIONS as it does NOT stop anaphylaxis (a potentially life threatening and rapidly progressive body-wide reaction).
Benadryl may help a rash from a skin contact to a food allergen, but it takes 30 to 60minutes to begin working. Always wash off any area on the skin where a food allergen has contacted.
There is NO HARM in giving an Epi Pen or Epi Pen Jr for a suspected food allergy reaction. Fast heart beat and shakiness are major side effects for about 15 to 20minutes, but failure to administer epinephrine injections or a delay has resulted in fatalities. .....

The comments after the OP's article are telling . . . very misinformed public.

Windchaser22 · Sep 20, 2016

Is there a self carry law in Illinois? In NJ I'm thinking this teen would have MD authorization to self carry.

allnurses Guide · Sep 20, 2016

Is there a self carry law in Illinois? In NJ I'm thinking this teen would have MD authorization to self carry.

We let students self-carry with an MD's ok . . . and our determination as well that the student knew what to do.

I've worked with some very savvy students who are diabetic and have pumps and then some who are not. Both had MD orders to care for their pumps w/o the nurse having to help.

I've had one scary incident with anaphylaxis where the student came to the office for help and didn't use her epipen even though she had an epipen and I wasn't notified right away. She was scared and wheezing and crying (the crying is good). Poor kid got the shot from me and a trip to the ER. And I went with her.

When she came back to school the next day, she brought me a hand-made card thanking me for "saving my life". I still have the card hanging on my fridge.

TriciaJ, RN · Sep 21, 2016

Interesting situation. There have been previous threads about "school nurses" not actually being nurses at all. Has anyone verified that the "school nurse" in this story is really a nurse?

In any case, we haven't heard from the nurse. We only have the student and her mother's input. Definitely not a complete story.

I still think the biggest onus is on the cafeteria people. What the H were they thinking?!

ComeTogether, LPN · Sep 21, 2016

The student walked to the nurses office and stated she had been "exposed" to peanuts. I would need more information to be certain, but it sure sounds like Mom is a bit cray-cray.

CaffeinePOQ4HPRN, BSN, MSN, LPN, RN · Sep 21, 2016

District 214 apologizes after nurse allegedly delays student with peanut allergy from using EpiPen - Chicago Tribune
Thoughts?

These days all Nursing seems to be is this:

Help someone

Delay helping someone

"do no harm"

Don't help someone (which we would never consdier b/c it's neglect)

Ask for assistance to help someone

All we (nurses) ever do is GET IN TROUBLE while trying to help the public. It's EXHAUSTING!

You can follow protocol perfectly and someone will still go out of their way to find fault with something you did and cause a stir or impact your professional reputation/career... most often when it's completely unwarranted and unfounded... even if no harm came to the patient(s) in your care. It's like we're just lining up for a firing squad to shoot us no matter what we do. Management and executives "brainstorming" efforts and all this patient satisfaction scores nonsense are negatively correlated to the commoditization of health care. It has directly contributed to the denigration of the nursing profession and the pressure we all feel in our day-to-day of just trying to make the world a better place. The respect Nurses used to garner seems to be bleeding out completely...