I taught two WFA classes in the last month, and between the two of them, I got to thinking. How common is this scenario? I started looking, and I learned a lot.
Now, for the record, I am currently certified at the Wilderness First Responder level. But I have been an active working Paramedic and EMT. I know a lot about this drug, and have pushed it a handful of times when working on the ambulance. A handful of times, meaning 3. 3 times in 5 years. Doing 8 to 15 calls a day. I have also been teaching in the outdoors for sliding up on 20 years. Okay, I am at 17 years. I have taught day long courses, and month long courses. I have had thousands of students. Outdoor programs always carry Epipens, to avoid the scenario above. I have never pushed epi on an outdoor course. I have never even come close.
I really should title this post, the over fear of anaphylaxis. Because that is what we have. For clarity sake, Of course anaphylactic reactions to allergens are a real and scary thing. If you have an allergy you need to carry an Epipen and you need to know how to use it. But the problem is we have convinced the world - or at least the population of the United States - that this happens a fair percentage of the time when adventuring. The problem is, there aren't any real studies about deaths from anaphylaxis in the backcountry.
But there are studies for the front country, and they are very interesting. There are three studies that people use, two of them lasted ten years, and the third was 4 years. They looked at death certificates and Hospital and ED discharge information. Here is what they found.
The authors found that case fatality rates were between 0.25% and 0.33% among hospitalizations or ED presentations with anaphylaxis as the principal diagnosis. These rates represent a total of between 63 and 99 deaths per year in the US, ~77% of which occurred in hospitalized patients. Rate of anaphylaxis hospitalizations rose from 21.0 to 25.1 per million population between 1999 and 2009. However, overall mortality rates appeared stable in the last decade and ranged from 0.63 to 0.76 per million population (186 to 225 deaths per year).
The primary cause of Anaphylaxis is reactions to medication - usually antibiotics. These numbers are staggeringly low. This is just not something that is happening that frequently. Despite what we are told, this really isn't something we need to be worried about.
But, those numbers are for the front country. What about us enjoying the back country where we are exposed to the elements, and more importantly, Bees! There just isn't data...
Or is there? I work for two very large outdoor companies. surely they keep records? right? They do. I emailed them both, and I am not going to share whose information I am relaying, frankly because I don't know if I am allowed to. But here is what I was told. For the decade prior to last year, instructors pushed epinephrine 5 times. 5 times in ten years averaging about 4000 students a year. That is .0125%. But importantly, I don't know what the cause of anaphylaxis was. But why does this exclude last year? because last year was an anomaly. Last year there were 11 instances of epi being pushed on a course.
Almost all were the students own Epipens being used. Again I have no data as to signs or symptoms of the patient. But 11 instances in one year is .275% - It is statistically impossible for that many students to have gotten Anaphylaxis in one year on courses. Which means, Epi was pushed when a life threat wasn't occurring.
Why would that happen? Because we have made everyone afraid of Anaphylaxis, and we think it occurs all the time. We are confronted by someone telling us they are allergic, and had an exposure. They will get an anaphylaxis reaction, and they will die. So we push epi. The big give away, that they are worried about something that isn't going to happen, is they can tell us. If you can say "I need my Epipen", you don't need your Epipen. Here are signs and symptoms of Anaphylaxis
The first signs of an anaphylactic reaction may look like typical allergy symptoms: a runny nose or a skin rash. But within about 30 minutes, more serious signs appear.
There is usually more than one of these:
- Coughing; wheezing; and pain, itching, or tightness in your chest
- Fainting, dizziness, confusion, or weakness
- Hives; a rash; and itchy, swollen, or red skin
- Runny or stuffy nose and sneezing
- Shortness of breath or trouble breathing and rapid heartbeat
- Swollen or itchy lips or tongue
- Swollen or itchy throat, hoarse voice, trouble swallowing, tightness in your throat
- Vomiting, diarrhea, or cramps
- Weak pulse, paleness
We also used to think that it was common to have what is called a biphasic reaction, meaning you have a reaction, get hit with Epi, then you get better and up to 24 hours later you get a second reaction. We used to think it happened close to 30% of the time. Now we know it happens less than 1% of the time. (though web MD says otherwise, I trust my medical directors more!)
We live in a culture of fear. We are told to be afraid of something, and then told what to do about it, which invariably leads to us spending money. I am not saying you shouldn't carry an Epipen if you have an allergy. But if you don't have an allergy, you don't need one.
The other thing you don't need is quick clot or a tourniquet. But I will leave that for another day..
Link 1 for data
Link 2 for data
Link 3 for early evidence of the culture of fear we live in.