April 28, 2011

A Case for Improved Risk Protocols

Mike Colpo
NOLS Instructor

Campus Recreation programs offering outdoor components face a threat far more real and menacing than a crashing economy. This hazard brings stress, chaos, and in extreme cases, death — and it is almost entirely beyond our control. It is a nefarious agent, too, in that many of us have unwittingly served as vectors for transmission of its typically surprising attacks. Those who have dealt with it before know it well; the memory of its effects conjuring images straight out of The Exorcist or Poltergeist. Yes ladies and gentlemen, I’m talking about the lowly peanut.

Of course, the peanut here can just as easily be replaced by bee stings, gluten, latex, or any item from the growing list of allergens that effect today’s students. Are the immune systems of today’s students less robust, or have our methods of tracking and understanding allergic response mechanisms improved? The debate remains open, with elements of truth scattered liberally on both ends of the spectrum. Regardless of where the answers lie, the truth for Recreation Program Coordinators remains immutable — all programs which offer students educational, recreational, or social programs that could expose them to uncontrolled (or uncontrollable) environments need a coordinated strategy for responding to environmentally introduced allergens.

The best defense against sudden anaphylaxis is the EpiPen. Epi-Pen is an auto-injector that administers epinephrine–and epinephrine is the definitive emergency treatment for severe allergic reactions. Called anaphylaxis, these severe allergic reactions are marked by swelling of the throat or tongue, hives, and trouble breathing. When it strikes, life is at risk. And time is critical, since anaphylaxis can become fatal within minutes if untreated.

Historically, concern for this type of risk has been the province of dedicated outdoor programs. It has become an industry standard that any type of programming which takes students beyond the boundaries of the campus to participate in a physically demanding activity in an uncontrollable environment requires staff to have a Wilderness First Aid, or more typically, Wilderness First Responder certification. The training provided in these certification courses prepares professionals for the unique challenges of dealing with the kinds of emergencies for which rapid response is required, yet unavailable (through limiting factors such as terrain, remoteness, etc.). The curricula for these certifications share a fundamental assumption, namely, that a higher level of care should be provided when students are participating in a school-sponsored activity that places them outside the reach of emergency medical care that can be provided within the ‘golden hour’. Most programs provide screening tools and considerable information concerning inhalers, epi-pens and the like when going into the field. Many programs require students with know allergies to carry an epi-pen and others exert even more control by requiring the student to bring two – one of which remains with the instructor in case the student loses or damages the first dose.

While this makes immediate sense for a school that offers students the chance to raft a section of wild whitewater in a remote mountain canyon, it’s not immediately obvious how these protocols can be positively transferred to on-campus settings. But violent allergic reactions command a special level of attention for the speed at which these attacks affect sufferers. The first-aid training typically provided to program staff assumes their care will be provided in a front-country situation in which EMS can be expected to arrive within the golden hour. Those who’ve witnessed or participated in virtually any on-campus outdoor activity with a successful level of turnout (i.e. a live concert, spring career fair, Greek games, intramural championships, etc.) know that it’s not hard to create the kind of critical mass of crowds and traffic that could keep EMS from responding promptly enough to assist a victim with a rapidly constricting airway. In many urban and suburban settings where campuses are located, appropriate priority one response times for EMS are up to eight minutes. Imagine eight minutes on an intramural field waiting while a student suffers an anaphylactic reaction from a bee sting. For this reason, all programs need clear response protocols to guide them through these rare high-consequence situations.

Developing an Epi-Pen Risk Management Plan

1. Identification of Individuals at Risk
– It is the responsibility of the anaphylactic/potentially anaphylactic individual to inform the University of their allergy. All members of the department in which a potentially anaphylactic individual is participating should be made aware of the individual’s potential for anaphylactic shock.
– Each individual who has the potential of anaphylactic shock should wear a medic alert bracelet that states his/her allergy(ies) and the location of his/her auto injector(s) (EpiPen).
– Obtain permission from individual in writing to allow administration of the Epi-Pen by a staff member in situations where the affected individual is unable to self administer the Epi-Pen.

2. Availability and Location of EpiPens
– Anaphylactic/or potentially anaphylactic individuals should carry at least one EpiPen with them at all times and have backups available at the University. As a precaution, the potentially anaphylactic individual should supply their department with two extra epi-pens in case of an emergency.
– It cannot be presumed that adults will self-administer their auto-injector.
– A Fact Sheet and directions for use of an EpiPen should be posted in departments where the potentially anaphylactic employee works. (See Fact Sheet boiler plate below)

Epi-Pen Fact Sheet
General guidelines for administration of the Epi-Pen.

With increasing numbers of individuals with severe allergies, individuals are concerned about the possibility of administering emergency procedures such as epinephrine auto-injectors, commonly known as EpiPens. Administering the EpiPen could save a life. Failure to do so could result in serious illness or death. Therefore, the University wants you to know that:

– the EpiPen is easy to administer
– the EpiPen does not pose a health risk to individuals, even if it is administered unnecessarily
– the EpiPen can be self-administered, but it should generally be done with the assistance of a competent person because the on-set of anaphylaxis can be debilitating

3. Treatment Protocol
– Individual treatment protocol is usually established by the individual’s allergist. The University cannot assume responsibility for treatment in the absence of such a protocol. All EpiPen containers include a patient insert with important information of when to use the EpiPen and how it should be cared for and stored.
– Please note: EpiPens can be stored in areas where the temperature is up to 25 degrees Centigrade (77 degrees Fahrenheit).
– Do not store EpiPens in refrigerators.
– Do not expose EpiPens to extreme cold or heat.
– All auto-injector EpiPens have an expiration date — for example: December 05 = December 31, 2005
– All EpiPens need to be replaced before the expiration date.
– Examine contents of the EpiPen occasionally through the clear window to ensure that the solution is not discoloured or contains solid particles (precipitate). The solution should be clear and if it is not, the potentially anaphylactic individual should replace the unit immediately.
– To manage an emergency, please do the following:   Call 911.

  1. a. One person stay with the injured individual at all times.
  2. b. One person goes for help.
  3. c. Patient of authorized staff member administers epinephrine at the first sign of reaction, however slight (e.g. itching or swelling of the lips/mouth in food allergic individuals). There are no contraindications to the use of epinephrine for a potentially life-threatening allergic reaction. Note time of administration.
  4. d. Regardless of the degree of reaction or exposure to epinephrine, transfer the individual to an emergency room asap. Symptoms may reoccur up to eight hours after exposure to the allergen.
  5. e. Contact the individual’s emergency contact.

4. Training
– Each year, the Education Health Centre or a medical professional should provide an awareness session for all staff, which includes a demonstration on the use of the epi-pen.
– All EpiPen cases have a patient insert that gives information on how to administer an epi-pen.
– On the web, http://www.epipen.com/howtouse.aspx demonstrates how to use an EpiPen.
– The directions for the use of an EpiPen should be posted next to this fact sheet. Remember: if the directions for use are missing, each EpiPen tube/case has the directions for use inside of the tube.
– Professionals should be trained in recognizing Anaphylaxis symptoms and signs, and the possible side effects following the administration of epinephrine. NOTE: Symptoms develop rapidly, often with seconds or minutes of the allergen or factor causing anaphylactic shock.

Lastly, a clear understanding of your state law and local protocols concerning the use and administration of any medication is necessary. Discussions with legal council and university administration should thoroughly examine the issues and potential exposures associated with Epi-Pen administration.

Mike Colpo has instructed for the National Outdoor Leadership School (NOLS) for the last ten years. In addition, he has taught outdoor programming at the community college and university level. He is currently Web Editor for Patagonia.

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