I am wondering how anaphylaxis was not mentioned in the differential diagnosis/considerations for respiratory distress in children, especially in the upper airway segment of your January article “Crashing Hard and Fast.” It is perhaps one of the easier causes of respiratory distress to treat in the prehospital setting with IM epinephrine. As was stressed to me early in my medical education, the diagnosis you will never make is the one you don’t consider. In a 2013 retrospective chart review published in Prehospital Emergency Care, epinephrine was administered in 41% (89) of 218 cases receiving care in the pediatric ED for anaphylaxis. The conclusion states, “Our evaluation revealed low rates of epinephrine administration by EMS providers and parents/patients. Education about anaphylaxis is imperative to encourage earlier administration of epinephrine.”
—Dean Parker, MD, MPH
Author’s response: Thank you for your input. I would consider respiratory distress secondary to an anaphylactic reaction as a potential differential diagnosis for upper airway distress in pediatric patients. It wasn’t included in this article in part due to keeping the article as brief as possible, but with anaphylaxis, although possible, generally respiratory involvement would not be an isolated sign. With anaphylaxis I would also expect to see a more systemic picture, including swelling, hives, itching, and difficulty swallowing. You may also see GI symptoms, including GI distress and diarrhea as the reaction continues and you have a prolonged histamine release. I remind everyone to follow local protocol. With severe anaphylaxis, for us that would be epinephrine 1 mg/ml 1:1,000, 0.01 mg/kg, not to exceed 0.3 mg IM for pediatrics, and epinephrine 1 mg/ml 1:1,000, 0.5 mg (0.5 ml) IM for adults.
—Roger Smith, NRP
Psych Patients to the ER?
Thank you for your article “Medical Clearance of Psych Patients” [Journal Watch, January 2019]. I am one of those patients. I’m taking medication, and I haven’t had a psychiatric episode in several years.
I agree with the conclusion of the study. Diversions to psychiatric facilities would save a lot of time. There have been a few times when I’ve asked for help. Physically I was perfectly healthy. Mentally, that’s another story.
I’ve spent many unnecessary hours in the ED before being transferred to the proper facility. Why? Like the article says, if I’m not in a medical crisis, why do I need to go to the emergency room?
If I’m not in the emergency room, that’s another bed for someone else to use. It frees up the time of the responders and nurses who would be treating me. It also relieves the anxiety of the waiting patient, as well as the family around them. Keep families in mind. They are worried and concerned about their loved ones as well. No transfers!
I became an EMT in the mid 1990s at age 18. Five years later I was a medic. My biggest fear was psych patients. I thought they were untrustworthy, unpredictable and basically crazy. I was always on edge with them.
That is, until I became one myself. Psychiatric patients deserve better care and more dignity, not our biased opinions and judgement.
—Name Withheld Upon Request
Lights and Sirens Use
Speed kills. Remember, fewer than 3% of EMS transports are for critical patients. Additionally, given that 60% of ambulance crashes and 58% of fatalities occur while lights and sirens are being used, it behooves us to use them as little as possible.
Ask yourself whether using lights and sirens will decrease your response or transport time enough to warrant their use. Is the dispatch for a high-acuity call? Can you make up the time getting out the door or arriving to the patient’s side more quickly? A study in Washington, D.C., by the George Washington University Department of Emergency Medicine found that, on average, lights and sirens reduced rolling response times by just 45 seconds.
In all but the rarest of cases, use of lights and sirens won’t make a difference to the patient, but it could kill you. Think about your speed. Dead EMS personnel save no one.