If your child suddenly can’t breathe, most likely your instincts will move you to call 911.
But what if the only medication that can save your child’s life isn’t aboard the ambulance when it arrives?
So may be the case for children — and adults — with allergies.
Epinephrine is the only medication known to stop anaphylaxis, a life-threatening allergic reaction that can cause shock, a sudden drop in blood pressure, trouble breathing, and even death.
However, not all ambulances are required to carry epinephrine.
“We think of 911 as the first call we would make when anyone has an emergency including a food allergy reaction. To think that emergency responders could show up and be little to no help at all possibly when you so desperately need it, is beyond devastating,” Erin Malawer, mother of a child with allergies and a blogger at Allergy Shmallergy, told Healthline.
Food Allergy Research & Education (FARE) reports that every three minutes a food allergy reaction sends someone to the emergency department, resulting in more than 200,000 emergency department visits per year.
Chances are that number will increase given the fact that food allergies among children has grown 50 percent from 1997 to 2011.
“It’s clear that allergies are on the rise, and that anaphylaxis emergency treatment is a concern,” Jennifer Jobrack, senior national director of advocacy at FARE told Healthline.
Jobrack points out that FARE’s Food Allergy & Anaphylaxis Emergency Care Plan, which outlines recommended treatment in case of an allergic reaction, is signed by a physician and includes emergency contact information.
It also states that if someone is experiencing anaphylaxis, epinephrine should be administered and 911 should be called.
“So we make an assumption that that’s the right course of action because 911 is going to show up and know what to do. What we have found is that that’s not always the case,” said Jobrack.
So why aren’t all ambulances required to carry epinephrine?
A matter of training
The National Highway Traffic Safety Administration (NHTSA) is the federal agency that defines the scope of practice for emergency medical responders who work on ambulances.
Each state tends to have three types of responders, including basic and intermediate emergency medical technicians (EMTs) and paramedics. Paramedics have the highest level of training and in most cases, EMTs have the least. The scope of each responder varies depending by state. For instance, EMT-Basics may not have access to epinephrine or may not be able to administer it even if it’s on board the ambulance.
The type of ambulance is also a factor. Most states have two types of ambulances: Advanced Life Support (ALS) and Basic Life Support (BLS).
ALS ambulances are typically staffed with paramedics and carry epinephrine, whether in the form of an ampoule, syringe, or auto-injector. Local medical directors and EMS entities often determine whether or not BLS vehicles are equipped with epinephrine.
“Sometimes BLS and ALS is defined by who’s staffing the rig and sometimes they’re defined by what medications, interventions, and remedies are on the rig, so it’s a confluence of circumstances to have a person who is authorized to use epinephrine on a vehicle that stocks epinephrine,” said Jobrack.
She added states can surpass NHTSA and refine the levels of EMTs they recognize.
In a state by state analysis that FARE conducted, it looked at how states define EMTs, what they’re allowed to do, and how ambulances are staffed.
For instance, FARE discovered that in Alabama, EMTs staff BLS vehicles while ALS ambulances may be staffed by intermediate or advanced EMTs, or paramedics. Intermediate or advanced EMTs and paramedics are required to carry either ampoules or syringes of epinephrine.
“So in their case, they’re defining presence of epinephrine on who’s in the vehicle. Other states may keep it with the rig rather than the person staffing it,” explains Jobrack.
Grasping the case in your area is a lot for parents to take on, says Malawer.
“You really have to understand who is going to show up or you have to make sure the 911 dispatcher knows the best vehicle and responders to send. All of that is a lot for parents to understand, especially during a crisis situation when they may not think to ask,” she says. “Plus, if I thought an ambulance was coming that didn’t have epinephrine, I would think twice about waiting around.”
Reluctance to administer epinephrine
FARE also conducted a 2013 survey of about 3,500 members in 47 states to find out what their experiences were when calling 911, when an ambulance arrived, and what occurred in the emergency room.
Of respondents, 49 percent called 911 due to an allergic reaction. Epinephrine was given before an ambulance arrived 58 percent of the time. Data showed that when people received emergency medical care, epinephrine was not usually the first drug of choice to treat anaphylaxis.
“People got antihistamines, steroid treatments, and oxygen first,” Jobrack says. “There’s a consensus that even among seasoned emergency medical professionals there was a reluctance to use epinephrine. We don’t understand it because epinephrine is known to be a safe drug with minimal short-term side effects that works quickly, and is the only medication that can stop the symptoms of anaphylaxis.”
Lack of understanding of the symptoms or path of anaphylaxis may be to blame, notes Jobrack.
For instance, members of FARE reported several times in a survey that an ambulance showed up after an anaphylaxis reaction occurred, and the person was given epinephrine that belonged to them or a bystander.
“Since the symptoms might have subsided, there was reluctance on part of the medical professional to take the person to the hospital. Comments like, ‘You’re fine now,’ and, ‘He’s all better,’ were said. But we know that biphasic reactions [a second episode of anaphylaxis that occurs with no additional exposure to the allergen] are not uncommon and best practice is that a patient who experiences an allergic reaction be observed for four hours,” Jobrack says.
FARE’s survey also found that while respiratory symptoms and skin symptoms such as hives or swelling are recognized as common symptoms of anaphylaxis, gastrointestinal symptoms, especially vomiting, were overlooked.
“We have work to do to reinforce all the different ways anaphylaxis presents itself and enforce the importance of not hesitating to give epinephrine. There is no substitute,” she says.
What can you do?
FARE encourages people to visit their local ambulance provider and learn about the EMT and epinephrine coverage in your area.
Emergency medical services could be determined by the county or city, depending on where you live. They may also be run by the local fire department or hospital.
Good questions to ask include:
- What types of EMTs respond to a 911 call?
- What types of EMTs can administer epinephrine, and in what form?
- Are all ambulances equipped with epinephrine, and in what form?
Malawer visited her local fire department and asked the above. She learned that she lives in an ALS-only system.
“Made me feel safe for a moment, but then I thought about when I’m traveling outside of my area. I can’t make a call to every county that we’re visiting. That seems absurd. Something needs to change,” she said.
No matter where you are, Jobrack says your best approach is to tell the dispatcher that someone is experiencing anaphylaxis and to send a vehicle with epinephrine on it.
“Don’t worry about saying a BLS or ALS ambulance because depending on where you’re at, a BLS vehicle may have epinephrine on it. It’s not our call as callers to know that,” said Jobrack.