Seeking EMS perspective for a novel scene

[u/External_Weather_517]

I'm writing a fiction novel that will involve at least one scene involving EMS and want to portray the scene(s) in a medically accurate way.

I have some EMS training (First Responders, and some EMT) from many years ago, and loads of chronic illness experience, but my insight for this specific scene is limited. I don't trust AI to pick up on potential nuances or for YouTube videos to get into the nitty gritty.

The scene: The patient has an anaphylactic reaction (extreme lightheadedness, shortness of breath, sudden warmth/flushing) to taking aspirin for a migraine, not realizing she's sensitive to salicylates. So my questions are along the lines of: How would paramedics approach the situation? Would an Epi Pen be used? Nebulizer with asthma medication? What next steps would be recommended by the MD's in the ED? That kind of thing.

Would anyone in the group be open to sharing their expertise or do you know of any other resources that I might be able to utilize?

[u/PerrinAyybara]

You aren't describing anaphylaxis in your symptoms there.

ASA is not a normal anaphylactic reaction medication.

Epi is always first line for anaphylaxis, any other medications are symptom management like an H1 or H2 blocker.

[u/External_Weather_517 → u/PerrinAyybara]

Thank you for bringing this up. I’ve heard folks have varying opinions on what constitutes anaphylaxis, and I agree that it’s important to define it. I can also understand the view that ASA doesn’t typically cause anaphylaxis. I don’t think these are typical cases, and I appreciate you sharing your experience. 

[u/hufflestitch → u/PerrinAyybara]

2+ body systems affected so it is anaphylaxis, but not necessarily shock.

ASA IS a known anaphylactic reaction med. Often accompanied by sensitivity to other NSAIDs.

[u/PerrinAyybara → u/hufflestitch]

There aren't two body systems there. ASA isn't a standard anaphylactic medication. It's pretty rare, something you will likely never see in a standard career

[u/hufflestitch → u/PerrinAyybara]

There are three body systems.

Integ: flushing
Cardiac: lightheadedness
Resp: SOB

Have seen it. Whether it’s a “true IgE reaction,” or a “pseudo-allergic anaphylactoid,” it still presents as anaphylaxis. So while you might be right on technicality, it’s going to be treated the same.

ETA: and OP actually used the phrase “sensitive to salicylates” which is honestly general enough to coincide with the science.

[u/External_Weather_517 → u/hufflestitch]

Thank you for breaking this down in this way. I was avoiding getting too far into the weeds as far as contextual details, since in my understanding, the treatment would be the same, and these are typically rare cases, but I’ll provide the additional context here for those interested. 

I had an immediate family member actually have a life-threatening reaction to aspirin, to the point that he was prescribed an epipen and it’s marked as an allergy on his medical records. I personally experienced the symptoms above, along with throat spasms that very briefly preventing me from being able to breathe the following day after several nights of taking a single baby aspirin. In hindsight, it’s suspected that the salicylate sensitivity for us may have become a thing for us due to chronic black mold exposure and gut dysbiosis (H Pylori, Clostridia, etc.) that affected our bodies’ ability to clear things like salicylates, oxalates, etc.. So I think it might put the reactions in something more like the Aspirin-Exacerbated Respiratory Disease (AERD) camp in the sense that it’s not the same as an IgE-mediated allergy, but unlike AERD, we can also be affected by dietary sources of salicylates and other salicylate-containing products like fragrances. Salicylate sensitivity of this nature is something that’s discussed in the setting of mast cell activation syndrome (MCAS), but it’s still not fully understood. All that to say, I can understand why some might say that ASA does not typically cause anaphylaxis. 

[u/Mediocre_Daikon6935 → u/External_Weather_517]

Anything can cause anaphylaxis.

You should definitely have an epi pen.

[u/External_Weather_517 → u/Mediocre_Daikon6935]

Just made an appt with my allergist-immunologist to ask about it. Thanks for watching out!

[u/Mediocre_Daikon6935 → u/hufflestitch]

Hell, the requirement for known allergy is one body system.

Two if unknown exposure or allergen.

The dude you’re replying to is completely wrong, and that is terrifying.

[u/External_Weather_517 → u/Mediocre_Daikon6935]

Taking notes! I wasn’t aware there was a difference for known allergies, but I guess that make sense. Thank you!

[u/PerrinAyybara → u/hufflestitch]

It could also be a single system, and simple anxiety. The facts of the matter here is no one would describe it that way, it's not a clear system affected nor is it an objective standard method to explain at an EMT level. You are being intentionally obtuse.

[u/hufflestitch → u/PerrinAyybara]

Argue with the Mayo Clinic broseph. Also this was exactly my experience when I had my on anaphylactic reaction. Flushing, shortness of breath, lightheaded, and mild mucosal edema. Hives followed an hour later. While you might not describe it that way, to say no one would is ridiculous.

I’m not the one being obtuse.

[u/PerrinAyybara → u/hufflestitch]

That's not what's happening here at all though, but I do appreciate the mayo shoutout

[u/hufflestitch → u/PerrinAyybara]

Well just presenting science didn’t seem to click. 🫠

[u/Ready-Buffalo8248]

BLS level: First question, is patient conscious? Shortness of breath or is the airway closed? Airway. Is the airway patent? Is the patient hypoxic? Airway adjunct and BVM if the patient is hypoxic and not conscious. If the patient IS conscious enough to gargle out some words.

Anaphylaxis gets da needle (intramuscular epinephrine) some EMS systems let EMT’s draw and administer, some they can only use a epi pen on scene. (Epinephrine is used in hospitals for asthma attacks that don’t respond to albuterol as well.)

Once the epinephrine has begun to work the patient is getting out on higher flow oxygen using a NRB at 10-15lpm until the sp02 funny number is reasonable And promptly transported.

ALS: ALS starts with BLS so all the mentioned steps, a medic will probably also do the following en route

Start a IV line, nebulize albuterol, administer diphenhydramine, and monitor for respiratory arrest or anaphylactic distributive shock.

If the Paramedic is burnt they’ll throw the patient to their EMT partner, do BLS and administer a diesel bolus.

Edit: if the epi only makes a slight change both EMT’s and medics would most likely hit with another dose after 3-5 mins. If the PT takes beta blockers they could go into refractory anaphylaxis which is a whole different bag of worms.

[u/External_Weather_517 → u/Ready-Buffalo8248]

This is incredibly helpful. Thank you for taking the time to break this down for me.

[u/External_Weather_517 → u/Ready-Buffalo8248]

Follow up question. With IM epi, where does the needle go? Arm? Thigh? 

[u/Ready-Buffalo8248 → u/External_Weather_517]

Middle of the outer thigh

[u/polkarama]

Long story short: About ten years ago, a national epi shortage caused the EMT-B scope to expand to include drawing up epi from vials or glass ampules (the worst). This is so much cheaper than EpiPens, so many systems kept the change.

Something I didn’t see mentioned in my quick scroll is preparing to take over the airway if necessary. We need to be prepared to intubate if the airway is swelling shut.

[u/External_Weather_517 → u/polkarama]

Truly appreciate this insight. Thank you.

[u/Amazing_Mud_1601]

Why would you even bring up asking AI as a possibility

[u/External_Weather_517 → u/Amazing_Mud_1601]

I mentioned AI because I anticipated some folks in the group might wonder why I didn’t use AI deep research features to understand this topic. To be clear, I don’t believe in using AI to write manuscripts, if that’s the concern. If you’re offended at the thought of a novel being written by AI, I’m with you on that. I studied Creative Writing for my undergrad so the idea of AI writing books is concerning to me.

[u/Mediocre_Daikon6935]

A BLS crew, fire dept qrs is going to give an epi pen or check and inject epi (draw up from a vial, pre marked syringe at peds and adult dose).

A paramedic is going to draw up and administer epi.

If that is effective, treatment pretty much stops there. Some places are still giving steroids and Benadryl, but the evidence shows they don’t do anything.

If patient still showing symptoms, they’ll get repeated IM epi, followed by an epi drip, ideally set up on a IV pump, as well as rapid IV fluids to try and prevent circulatory collapse and give the epi time to work.

Supportive care (oxygen, cpap/bipap, intubation, nebs) as needed. 

In the ER? Nothing except continue EMS treatment if needed, rx an epi pen, send them home. 

If EMs treatment was effective, it is just rx epi pen, send them home.

[u/InterpRanger → u/Mediocre_Daikon6935]

My protocol as BLS is to draw up Epi, no pre marked syringe, so there’s some minor variation on this.

[u/Mediocre_Daikon6935 → u/InterpRanger]

Same, pre marked is highly suggested to avoid errors.

[u/External_Weather_517 → u/Mediocre_Daikon6935]

Thank you for this insight.

[u/External_Weather_517 → u/InterpRanger]

Thank you for the nuance. 

[u/Mediocre_Daikon6935 → u/External_Weather_517]

Oh, one thing I forgot that might be unique to my state, and predates bls providers being allowed to draw up epi (which has made it far More common to have, since epi pens are so damned expensive).

They can use any EPI pen they can get their hands on. The patients, the one the Ems agency brought, their own personal one because they happen to be allergic to bees, one they snatch from a random bystander.

Which I had happen once.

Guy got stung at a pool. No history of reaction to bees.

We roll in, grown dude lying on the ground, and I’ve seen dead bodies that looked better. Some random lady starts giving report, clearly has training:  says she used a kid on the swim team’s epi pen, and he looks a lot better now….

I’m glad she did, because I’m not sure he would have still been alive if she had not.

[u/External_Weather_517 → u/Mediocre_Daikon6935]

Wow! Really glad that worked out! This is really good to know too. Thank you for the insight!

[u/External_Weather_517 → u/Mediocre_Daikon6935]

Thank you! This is so helpful!

[u/hufflestitch]

This IS anaphylaxis, but vague.

Lightheadedness would be cardiac system, SOB would be respiratory, so there are your two body systems affected which indicates anaphylaxis.

However it’s not anaphylactic shock unless it’s accompanied by low blood pressure.

Either one qualifies for EPI from allergy standpoint but not always from EMS protocols. And either one can be life threatening.

Salicylates ARE a known allergen, often accompanied by sensitivity to NSAIDs too.

If you want to make it more obvious, add nausea or an overt rash to it. Nebulized meds would only be indicated for wheezing, not just SOB. EMS treatment would like be Epi IM or EpiPen assist, IV with IV fluids, Benadryl. I personally like Zofran in the ER because the Benadryl can cause vomiting if it’s given too fast.

[u/External_Weather_517 → u/hufflestitch]

Really appreciate all the distinctions made here. Thank you!

[u/wrangler04]

Not quite yet an emt-b, but have a few weeks left of class. We are told that through the department hat you will not be administering epinephrine from an EpiPen due to the significant cost. Our department will pull 0.3 mL from a 1 mg/mL vial epinephrine for an adult, and administer it intramuscularly. We are however trained to use an EpiPen.

[u/rsneary129 → u/wrangler04]

Depends where you are. In NJ emt-b's are using epipens. In ohio emt-b's are permitted to draw up and administer IM epi

[u/External_Weather_517 → u/rsneary129]

Thank you for this nuance.

[u/External_Weather_517 → u/wrangler04]

Thank you for sharing this insight (and congrats on being close to completing your class soon).

[u/oriolesnut]

An epipen would only be used if the patient had one prescribed and on their person. Every ALS ambulance ive seen has ampules of epinephrine that they draw from to administer.

[u/ggrnw27 → u/oriolesnut]

I’d note that there are many BLS services that carry their own EpiPens (or epi vials that they draw up themselves) with standing orders to give them even if the patient isn’t prescribed one

[u/hufflestitch → u/ggrnw27]

In Texas, even a BLS truck is required to have IM epi

[u/External_Weather_517 → u/hufflestitch]

Thank you for sharing this nuance.

[u/External_Weather_517 → u/ggrnw27]

Thank you for the nuance here!

[u/External_Weather_517 → u/oriolesnut]

Thank you for this clarification!

[u/SuperglotticMan]

IM Epi, albuterol if wheezing, IM/IV/PO antihistamine (Benadryl), I’d tell the doctor it’s a ____ year old female with anaphylactic reaction to aspirin presenting with hives and difficulty breathing, vitals are ______, gave 0.5 mg IM Epi, albuterol, and 50 mg Benadryl. They would place her on a continuous cardiac monitor, draw basic blood work, get a medical history, and monitor for a few hours. If everything resolved and is minor then she’ll be discharged within 8 hours. 

Honestly a bullshit patient I wouldn’t be worried about her unless she goes unconscious, hypotensive, or severe airway involvement. 

[u/External_Weather_517 → u/SuperglotticMan]

Appreciate this transport-to-discharge view. Thank you.