A correspondent asks
… a question regarding adrenaline (epipens) and anaphylaxis.There does not seem to be any clear directives, and indeed there are conflicting opinions on what you can/should do. Here’s a scenario:
Jim is an advanced first aider/medic working at an event. Tom presents with signs & symptoms of anaphylaxis. He has his own epipen which he used before seeing Jim. However, the effects of the adrenaline are wearing off, Tom is in clear respiratory distress, and the ambulance is still some 10-15 minutes away. Assuming that there is another person’s epipen available, does the reasonable medic isolate Betty (who owns the other epipen) and, assuming Betty agrees to “donate” her epipen, use her prescribed medication to treat Tom, and ultimately, save his life? Would a similar situation involving minors have different answer? Would a reasonable medic use the epipen?
An EpiPen is an auto-Injectors that delivers a measured dose of a synthetic version of adrenaline—epinephrine. (https://www.epipen.com/about-epipen/what-is-epinephrine). According to ‘NetDoctor’ (http://www.netdoctor.co.uk/medicines/allergy-and-asthma/a6668/epipen-adrenaline/)
EpiPen auto-injectors are prescribed to people who have a history or recognised risk of going into anaphylactic shock due to a severe allergy. The EpiPen is intended for self-administration, or administration by a family member or carer, in an emergency. Two EpiPens should be carried with you at all times…
The EpiPen is designed to be used by people with no medical training at the first signs of an anaphylactic reaction. “Adrenaline autoinjectors are available from pharmacies without a prescription at full retail price (not PBS subsidised)” (http://www.allergy.org.au/health-professionals/anaphylaxis-resources/adrenaline-autoinjectors-faqs).
In the Poisons Standard (June 2016) ‘epinephrine’ is referenced as ‘adrenaline’ and is listed in Schedules 3 and 4. If an epipen can be purchased from a pharmacy without prescription it must be in Schedule 3 ie ‘Pharmacist Only Medicine – Substances, the safe use of which requires professional advice but which should be available to the public from a pharmacist without a prescription’.
There are two types of epipen – “EpiPen (epinephrine injection) 0.3 mg and EpiPen Jr (epinephrine injection) 0.15 mg” (https://www.epipen.com/about-epipen/what-is-epinephrine). According to the Australasian Society of Clinical Immunology and Allergy (http://www.allergy.org.au/health-professionals/anaphylaxis-resources/adrenaline-autoinjectors-faqs, FAQ 20):
Higher dose adrenaline autoinjectors (yellow label devices) should NOT be administered to children under 1 year of age [but] In children aged 1 to 5 years of age … if only a yellow label device is available (containing 0.3mg of adrenaline) this should be used in preference to not using one at all.
What follows from that is that epipens aren’t ‘tailored’ for individual patients. A person either needs an epipen or they don’t. Using one person’s epipen is not going to deliver a different version or the dose of ‘epinephrine’.
A person who ‘… holds a current first aid certificate issued after completion of a first aid course approved by the WorkCover Authority … and the person has received training on the symptoms and first aid management of anaphylaxis’ is entitled to possess and use adrenaline (Poisons And Therapeutic Goods Regulation 2008 (NSW) Appendix C, cl 13). I will assume that Jim has completed approved training in anaphylaxis first aid.
In the scenario there is no issue of giving an epipen to someone who hasn’t had the relevant diagnosis. Both ‘Tom’ and ‘Betty’ have their epipen. The epipen may be ‘prescribed’ for Betty in order to allow her to buy it at a subsidised price, but we know that it will be the same as the epipen for Tom.
The question I ask is not whether Jim can use Betty’s epipen to save Tom, but what possible reason would stop him? Betty’s agreed, Jim’s trained and knows how to use it, and Tom needs it. In deciding whether or not a duty of care arises a key issue is ‘vulnerability’. Tom is vulnerable, he’s likely to die. Can he do something to protect himself? No, he’s not got another epipen. Can Jim? Not without Betty’s assistance but given Betty’s volunteered her epipen then he not only can see the need, he knows what is required and has the opportunity to do something. And he’s not a mere volunteer (ie someone who just happened upon the scene and volunteers to help) he’s ‘an advanced first aider/medic working at an event’ so Tom’s presumably come to him for help.
What are the costs? It deprives Betty of her epipen should something happen to her. One certainly couldn’t insist that Betty give up her epipen or take it from her, but if she volunteers it that’s fine. There is no limit on its use, it’s not a ‘prescription only’ drug and even if it is Jim is authorised to take possession of it from Betty and use it. There really is no reason not to do it. And every reason to do it. Imagine your Tom’s loved one and it turns out that when Tom was dying, Betty was saying ‘I have an epipen use it’ and Jim, the onsite first aider says ‘I won’t use that, it’s yours’ with the result that Tom died? If we accept that there is a duty of care, the test for breach is set out in the case that is quoted so often on this blog, Wyong Council Shire v Shirt (1980) 146 CLR 40,. There Mason CJ said (at p 48).
… what a reasonable man would do by way of response to the risk. The perception of the reasonable man’s response calls for a consideration of the magnitude of the risk and the degree of the probability of its occurrence, along with the expense, difficulty and inconvenience of taking alleviating action and any other conflicting responsibilities which the defendant may have. It is only when these matters are balanced out that the tribunal of fact can confidently assert what is the standard of response to be ascribed to the reasonable man placed in the defendant’s position.
The magnitude of the risk is that Tom’s going to die. I’ll leave it to clinicians to say how probable that is but remember we’re asked to assume ‘Tom is in clear respiratory distress, and the ambulance is still some 10-15 minutes away’. What’s the expsense of treating him? The cost of Betty’s epipen which she’s volunteering. Is there any ‘difficulty and inconvenience of taking alleviating action’? Only that it leaves Betty without an epipen. There are no conflicting responsibilities given Jim’s actually authorised to use and administer the drug. Failure to take action would appear to be an axiomatic case of neglect and negligence.
Does “the reasonable medic isolate Betty (who owns the other epipen) and, assuming Betty agrees to “donate” her epipen, use her prescribed medication to treat Tom, and ultimately, save his life?”
I can’t see how a reasonable medic would do anything else.
Would a similar situation involving minors have different answer?
No, even if Betty only had an epipen and not an EpiPen Jr it should still be used.
Would a reasonable medic use the epipen?
I can’t see how a reasonable medic would do anything else.
In Victoria during anaphylaxis management courses it is taught that an Epi Pen (or similar device) may be used every 5 minutes as required, where one is available, and it is permissible to use another persons epi pen on the provision they are willing to travel to hospital via ambulance also in order to reduce the risk of the person who donated the Epi Pen having an anaphylactic reaction while being away from an epi pen.
If using the above example, in Victoria it would be expected that Betty travels in the ambulance with Tom so that Betty is in ALS care until she can get her new Epi Pen, presumably from the hospital pharmacy and most likely with a prescription to unlock the PBS price.
Further to that comment, Luke, my original correspondent has got back to me and drawn my attention to this advice from the Australasian Society of Clinical Immunology and Allergy (“ASCIA”) (http://www.allergy.org.au/health-professionals/anaphylaxis-resources/adrenaline-autoinjectors-for-general-use):
I note that their advice is ‘If the individual whose adrenaline autoinjector has been used has anaphylaxis before their adrenaline autoinjector is replaced, they should be taken immediately to hospital by ambulance’ not they should be taken to hospital with the original patient. Whether you take them should surely take into account issues such as what are they allergic too? If it’s pollen and it’s mid spring, it’s probably wise, but if it’s ‘bee stings’ and their at an art gallery opening and there is a pharmacy reasonably nearby, perhaps not?
But Luke, what if they are not ‘willing to travel to hospital via ambulance’? Betty hands over her epipen, Jim says’ you need to go with the ambulance’ and Betty says ‘bugger that, I paid good money to get into this event and I’m not going to ruin my day just to help Tom and cover your backside’? Can you say ‘it would be expected that Betty travels in the ambulance’ or it would be ‘suggested’? ‘encouraged’?
This is interesting. I called an ambulance in WA for a friend’s child who was clearly having an anaphylactic reaction, and told the operator that I was willing to use my own daughter’s epipen for her. The operator said that because it wasn’t prescribed to the patient, they couldn’t recommend that course of action. We were in the metro area and the paramedics arrived quickly and gave her adrenalin, but I was a bit perplexed.., what are your thoughts?
Well presumably that was in the call takers script which is likely to be quite conservative as they don’t know what’s going on at the other end of the ‘phone. So they are likely to have a standard response of ‘never recommend using drugs prescribed for one person on another person’. Given the myriad of calls they’re going to take, the infinite number of conditions people have, the inaccuracy of information they’ll get (“Person B has the same condition as Person A so should I give A B’s drugs?” when really the conditions and drugs are quiet different) etc its probably a prudent cover all response.
Thank you for your article regarding the use of adrenalin autoinjection in such circumstances.
I was recently informed that in Tasmania, it is illegal and a “criminal offence” for individuals to administer another individuals adrenalin autoinjector, even in the circumstance of such device being volunteered to be used, in a life threatening situation.
As a medical doctor and volunteer for St John, it would seem to be an unfortunate legislation if it is true.
I would be grateful for your response. Thanks again for your great articles!
It’s really hard to argue a question like that. Without some detail of who told you and on what basis they gave their advice, it’s hard to refute their argument. Prima facie though (ie on its face) the proposition is rubbish.
Thanks for your article.
I am an anaphylactic and often wonder if I have my epi-pen on me and find myself in a situation where someone around me (for example in a cafe) requires an epi-pen but is not carrying their own, am i able to give them mine?
As per section 18 of the Poisons and Goods Regulation Act 2008 – `an epi-pen may be supplied by someone other than a pharmacist, where that person holds a first aid certificate. Therefore if someone next to me in a cafe is suffering anaphylaxis and requires an epi-pen, say the ambulance is still 20 minutes away but I have my pen available (and I myself am not in imminent danger of having an anaphylactic attack) – I am not legally able to supply it to them unless there is someone present with a current first aid certificate who I can give the epi-pen to administer it to the sufferer?
I think you’ve misunderstood regulation 18 of the Poisons and Therapeutic Goods Regulation 2008 (NSW). It doesn’t say an epi-pen may be supplied by someone other than a pharmacist. Reg 18(1) says
So if I go to a pharmacy to buy an epi-pen I have to see the pharmacist (not just the shop assistant) and the pharmacist has to give it to me and give me the opportunity to seek advice (not that the pharmacist has to give advice).
Clause (5) says that the rule in 18(1) does not apply if the person buying the epi-pen holds the relevant first aid certificate. If I do have that certificate I can go to a pharmacy and buy one or more epi-pens for my first aid kit and I don’t need to personally deal with the pharmacist.
The sections say nothing about the actual use of the epi-pen if someone is in crisis. If someone is in crisis you’re not supplying them with an epi-pen to put in their first aid kit, you’re providing first aid. If someone is suffering an anaphylactic reaction and needs an epi-pen, you have one and they don’t and the ambulance is 20 minutes away then of course you can give them yours. Whether that’s a good idea or not depends on your own risk assessment, ie what’s going to happen if you need one. Regulation 18 of the Poisons and Therapeutic Goods Regulation 2008 (NSW) doesn’t say you can’t do it and even if you did provided you are acting in an honest and good faith attempt to help you could rely on the NSW good Samaritan provisions.