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.