EpiPens and their manufacturer Mylan have been a topic of recent discussion, as the public becomes aware of the dramatic price increases over the past few years. This was not a surprise to the camp and school nurses out there, though. We have been feeling the pinch on our budgets as the price of epinephrine auto-injectors has increased. I will not target Mylan specifically because even the generic auto-injectors are priced at or over $500. Mylan set the bar high, and other manufacturers have kept pace. Even the now recalled AviQ injector was over $300 a set. I don't know just where making a profit became price gouging, but I do know that the high price of auto-injectors has led many camp and outdoor programs, as well as the lay public to seek alternatives.
For me this is not a new question, the wilderness first responders at my camp have been asking us for years to be provided with vials of epinephrine and syringes. The drawing up and administration of epinephrine in this manner is part of the ASHI WFR curriculum. I also recently encountered the following infographic advising laypersons to ask their doctor to provide them with vials and syringes to get around the expense of an auto-injector.
I have major reservations about using this technique in an on camp setting even with trained individuals and am strongly opposed to lay persons being provided emergency medications in this manner. A view shared by the management at my camp, which is why we have been spending thousands each year on auto-injectors.
Now one of the best parts about this blog is that it makes me ask myself “why?”. I know I am viscerally opposed to this method, my brain tells me it's unsafe, even for trained individuals, but in order to make my argument here, I have to show it... So here it is.
A 2001 study published in the Journal of allergy and clinical immunology demonstrated that even with clear instructions, a group of parents, took an average of 142 seconds to prepare an emergency dose. Compared with the control group of medical professionals which averaged between 29 and 52 seconds. The study also demonstrated that the epinephrine content of the parent's injection ranged forty-fold in contrast to the control group. The study concluded that most parents were unable to draw up an epinephrine dose rapidly or accurately. (1) For me, this clearly demonstrates that providing laypersons with a vial and syringe is a bad idea. This study was done under calm conditions, not under stress such as watching a child experience anaphylaxis.
But that study was about laypersons, not trained individuals, I can imagine my camp friends yelling out. Yes, that is true, there is no specific study on WFR or similarly trained individuals drawing epinephrine from a vial. This is because ASHI is the only organization that I am aware of that teaches it. ASHI's WFR training is highly specialized. It is designed for times when EMS and other forms of health care would be significantly delayed (2). As I understand it using a vial and syringe is practical in the backcountry, where multiple doses may need during an evacuation that could take several hours.
On camp and really most “wilderness trips” that your camp sends out will not be out of range of local EMS resources. So the on camp emergency would be more correctly addressed using traditional medical training and restrictions. The American Heart Association and American Red Cross both use auto-injectors in their basic and advanced first aid training. Emergency Medical Responder's and EMT-Basics, which are DOT and state regulated certifications, are trained exclusively on auto-injectors. Autoinjectors seem to be the standard of care in nonwilderness settings, so to do anything different on camp would be legally parlous.
Furthermore in many states the laws around the administration of emergency epinephrine by camp and school personnel, that specifically indicate the use of epinephrine auto-injectors in the language of the law. This applies to me in PA under house bill 1531 (3). You should read in its entirety any state laws that apply to your camps situation and consult your camps legal counsel before deciding to use a vial and syringe in place of auto-injectors, as the laws around this issue are rapidly changing.
In conclusion the use of a vial and syringe to administer epinephrine, as been scientifically demonstrated to be unsafe. Although a vial and syringe, may be advisable under wilderness conditions where other safer options are not available, this does not describe the majority of camps or camp programs. In the non-wilderness setting auto-injectors, are the standard of care, and often required by law. Auto-injectors are expensive, but required, until an alternative comes along.