Abstract
To the Editor:
I read the roundtable report on epinephrine with keen interest. 1 It's a thorny problem and I applaud those tackling it. A few points oblige clarification to further shed light on the risks, highlight breadth of the problem in the wilderness, and introduce another option in this confusing legal issue.
A well-recognized potential complication of epinephrine autoinjectors is accidental digital injection. 2 –4 A 20-year veteran emergency medicine provider in my hospital injected his thumb when trying to treat himself for anaphylaxis.
How big is this problem in the wilderness? I found only 1 citation 5 that would suggest it's a significant issue. I've been involved in 2 mountain rescue callouts for “bee sting anaphylaxis,” that were misdiagnosed. One was a bee sting without an allergic reaction; the other was syncope from dehydration and malnutrition. Maybe a study is in order?
The report blends 2 separate concerns that were discussed in Wilderness Medicine Magazine in 20076,7: (1) participants with known anaphylaxis should carry their own epinephrine; a lay bystander can assist a person in using their own medicine under some states' Good Samaritan laws; (2) the crux is whether a lay (unlicensed) guide should carry prescription epinephrine with intent to diagnosis and treat anaphylaxis, or, in short, practice medicine under protocol. Such recommendation would apply well beyond commercial outdoor schools: ski patrols, rural fire-rescue units, park and forest rangers, and search and rescue personnel. Are these organizations asking for similar capability?
Changing state legislation and lobbying medical boards are 2 excellent avenues. In Washington, certain birth control pills are available “under the counter” and physicians are allowed to prescribe certain antibiotics for partners of patients afflicted with sexually transmitted diseases. Another possible option, which wouldn't require haranguing with 50 states, is to ask the Food and Drug Administration to reclassify epinephrine autoinjectors as over-the-counter medication. While possibly farfetched and fraught with bureaucratic difficulty, it is nonetheless important to consider all options. Recategorizing as over-the-counter does not resolve the issue of training, as astutely pointed out by the authors. However, we do, after all, prescribe to and teach lay parents how to recognize and treat anaphylaxis in their kids with little more than brief instruction on using autoinjectors.