School nurse delays giving epi pen

[kidzcare]

"Officials at Township High School District 214 have apologized and agreed to pay the medical bills for a John Hersey High School freshman with a life-threatening peanut allergy, after a school nurse allegedly delayed her from using an EpiPen earlier this month."

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

Thoughts?

[Amethya]

I have a lot of students with severe allergies, but none of them supplied benadryl, just the epi-pen. But I do have adult benadryl, for the teachers, I guess in a emergency situation, I can use one for the students, but how much would I give a student? 1/2 of a tablet?

[MrNurse(x2), ADN]

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.

Not so much cray-cray as protective. Parents of chronic illness kids are hyper-vigilant when it comes to their kids, we kinda expect it from them.

[KatieMI, BSN, MSN, RN]

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

Oh, yeah.

Full spectrum there, from "get off your special horse, the world is not here to cater for special needs" to "Epipen is safe for a newborn".

We recently got a poor one LOL who happened to pass out in a restaurant after getting a tag too much of alcohol and got TWO Epipens, one from restaurant worker and another one from some good Samaritan. Both were thinking that "she might have an allergy attack and Epipen was a quick and safe way to help". Nobody figured to turn get head to the side, and 911 was called with a good delay. Result: HTN emergency, Vtach, intracranial bleed, aspiration, chronic vent with GCS below 7. Family is gonna sue Mylan for false advertisement and misinformation. I am not usually a fan of money-hungry lawyers but for this one I wish goid luck with all my heart.

[MrNurse(x2), ADN]

I have a lot of students with severe allergies, but none of them supplied benadryl, just the epi-pen. But I do have adult benadryl, for the teachers, I guess in a emergency situation, I can use one for the students, but how much would I give a student? 1/2 of a tablet?

Up to age 12, 1/2 tab is standard, but truthfully, it is hard to OD Benadryl with common doses (25-50mg).

[ComeTogether, LPN]

Not so much cray-cray as protective. Parents of chronic illness kids are hyper-vigilant when it comes to their kids, we kinda expect it from them.

I get being protective, but calling to verify with the parent before injecting her child with Adrenalin based only on subjective data seems pretty logical to me. I think involving the news and dragging the nurse through the mud is a bit much.

I'm just wondering what the nurses side to the story is.

[kidzcare]

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

I am in IL and yes there is. In my district, there needs to be a form filled out and they can self carry. Some students do, many do not.

I have a lot of students with severe allergies, but none of them supplied benadryl, just the epi-pen. But I do have adult benadryl, for the teachers, I guess in a emergency situation, I can use one for the students, but how much would I give a student? 1/2 of a tablet?

I'd be careful with that... If you give a drug with no order, even in an emergency situation, there could be consequences.

[Spidey's mom, ADN, BSN, RN]

I have a lot of students with severe allergies, but none of them supplied benadryl, just the epi-pen. But I do have adult benadryl, for the teachers, I guess in a emergency situation, I can use one for the students, but how much would I give a student? 1/2 of a tablet?

Benadryl does not work in anaphylaxis. And it takes a couple of hours to work for a skin rash.

Plus, you can't give someone a medication without a care plan/order in place.

Standard of care now says we go for the epipen first. That information has not trickled down to many schools as I'm noticing here on this thread.

The story about the intoxicated person getting stuck with an epipen twice doesn't pertain to the school setting at all. But yeah, bystanders shouldn't be doing anything except making sure the person is safe and calling 911. If they stop breathing or their heart stops beating, CPR trained folks should start CPR. But otherwise, wait for the ambulance.

​A life-threatening allergic reaction (anaphylaxis) can cause shock, a sudden drop in blood pressure and trouble breathing. In people who have an allergy, anaphylaxis can occur minutes after exposure to a specific allergy-causing substance (allergen). In some cases, there may be a delayed reaction or anaphylaxis may occur without an apparent trigger.If you're with someone having signs and symptoms of anaphylaxis, don't wait to see whether symptoms get better. Seek emergency treatment right away. In severe cases, untreated anaphylaxis can lead to death within half an hour. An antihistamine pill, such as diphenhydramine (Benadryl), isn't sufficient to treat anaphylaxis. These medications can help relieve allergy symptoms, but work too slowly in a severe reaction.

As mentioned in the article I linked previously, waiting is dangerous.

Tragic Loss Of Sacramento Teen Reveals Flaws In Anaphylaxis Guidelines

FACED WITH A REAL EMERGENCY, IT IS DANGEROUS TO WAIT FOR SYMPTOMS TO APPEAR UNTIL YOU GET ENOUGH” TO MAKE A DIAGNOSIS.Think about it in these terms: A person who has ingested their allergen is like someone sitting on top of a barrel of nitroglycerine which can explode at any time. Get the person out of there! Don't wait for even the first explosion; it may not give a warning and the destructive effect could be massive.

Symptoms can be rapid or delayed, symptoms in the same patient may be different from one episode to the next, so how can we use definitions and criteria that were designed to be used in a doctor's office, hospital or research study? Definitions and criteria that are not designed, nor for that matter researched for this application, for the typical real world allergic emergency.

For the same reason, some people call reactions mild” or severe” anaphylaxis. Maybe, and that is a big maybe, that could be done when calmly discussing things a few weeks after the event, but what about as things are evolving before our eyes? In this situation we currently apply criteria that do not work in an allergic emergency – anaphylaxis. Natalie did not develop anaphylactic shock 20 minutes after her eating a snack, she was in that process from the first bite.

[Amethya]

I'd be careful with that... If you give a drug with no order, even in an emergency situation, there could be consequences.

Plus, you can't give someone a medication without a care plan/order in place.

Standard of care now says we go for the epipen first. That information has not trickled down to many schools as I'm noticing here on this thread.

I understand that, but a lot of the parents tell me to give it to them, but it's like, you didn't give it to me to administer . And I don't have children's, only adults, because I have a drawer full of medications for the staff, not the children.

[JenTheSchoolRN, BSN, RN]

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.

Crying and talking, I know it is terrible to say it, but I am happy when a wheezing kid can do those things!

I have a Wonder Woman mug on my desk that I got from the student that I gave Epi to after peanut exposure. I treasure it.

I wonder if this nurse has never given Epi to a student. The first time you do can be terrifying! You're the only medical person, no back-up, your own heart racing a bit as you toy with the doubt that can be running through your head. The first time I did, I knew it was what I needed to do, but afterwards (when parent arrived just as ambulance was leaving, so I didn't go with the transport, they did) I was shaking like a leaf. This doesn't excuse it, of course, but is a valuable learning experience.

[coughdrop.2.go, BSN, RN]

I get being protective, but calling to verify with the parent before injecting her child with Adrenalin based only on subjective data seems pretty logical to me. I think involving the news and dragging the nurse through the mud is a bit much.

I'm just wondering what the nurses side to the story is.

I disagree. The student is old enough to know if they need an Epi-Pen or not. I would never delay emergency treatment to give Epi especially if the student already has a prescription for it. The provider has already deemed that medication and dose safe for that child.

As Spidey's Mom stated, Epi is standard of care. Subjective data or not.

[Lev, MSN, RN, NP]

I work with the adult population in the ED. (It may be different for kids). We do not jump to epi initially even if someone had a previous anaphylactic reaction. It depends on their symptoms. The medications we use for allergic reaction include IV solumedrol, benadryl, and pepcid and of course IM epi. I have given the above IV medications (not epi) to an asthmatic who was wheezing after being exposed to a nut she was allergic too with a good outcome. We do not always jump to epi. It depends on when they were exposed and what their symptoms are.

Again, I work with adults, so with kids and outside the hospital setting without a physician present, jumping to epi may be the right thing to do.

[Medic/Nurse, BSN, RN]

God Bless all the school nurses! I wouldn't last 1 day!

Now, I might be really confused about allergies, anaphylaxis, Epi-Pens, action plans, crazy parents (some are — que the bats!) , efficacy and wisdom of antihistamine use, onset of symptoms in food allergy exposure, and if Mylan is truly evil and trying to take over the world (actually I think they are, but hey!). Or I might not be so confused?

If you need it, you need it. If not it's a bad idea.

2 things are overly vexing me. 1 — has all assessment ability for determining if an impending anaphylactic reaction exists been surrendered to the "you ask, I deliver" a vague action plan for a nurse to simply do what the student says, regardless; and, 2 — when you call 911 doesn't a paramedic take over the matter?

FTR — pedi or adult, I've had limited occasions in the last 2 decades to give epi. If it's being given many times at your location every year, I'd think there's an issue based on my experience.