epinephrine

Do Uninformed ER Doctors Skip The Epinephrine?

epinephrineThe headline was both surprising and alarming: “Emergency Rooms Often Skip The Epinephrine For Severe Allergies.” In it, an allergist says, “I think moms are probably more aggressive than physicians are in using [epinephrine].” According to the article, 80% of the time, emergency physicians withhold lifesaving epinephrine from their patients.

On Twitter, people commented, “terrified now” and “this is kinda scary.”The image the article evoked, to us, was of a severely ill child in an emergency department, gasping for air while an uninformed physician fails to administer the same epinephrine that many parents use at home. Heart wrenching, haunting—and incredibly inaccurate.

The 80% number came from a German survey of physicians in general medicine and pediatric offices. The study did not include emergency departments, and the health system described is literally an ocean away from how we practice (German emergency systems and training are set up very differently than in the US). Nevertheless, it was cited without context to support the contention that emergency physicians are “really nervous” about giving epinephrine.

The story is concerning both for its failure to provide supporting data for its strong statements and for the false messages it seems to broadcast to the public:

  • Anaphylaxis is better treated at home than in a hospital.
  • Emergency departments do not treat anaphylaxis well; your allergist is the best expert.
  • Doctors cannot be trusted to start simple, life-saving treatments.

There are many reasons the article missed the mark about anaphylaxis and its treatment. To summarize responses from the emergency medicine community:

  • True anaphylaxis is an immediate, life-threatening emergency. The best place for it to be evaluated and treated is in the emergency department. Delayed, resurgent reactions are possible and may require additional doses of epinephrine.
  • Not all allergic reactions—even severe ones—are anaphylaxis. Not all, therefore, need epinephrine. Sometimes when patients come in saying they have anaphylaxis, they have none of its signs or symptoms. That is why we will sometimes wait and see, rather than diving in and giving a drug with potential for harm.
  • While extremely effective, epinephrine cannot be blithely described as “safe.” It is potent and can precipitate high blood pressure, irregular heart rhythms, and heart attacks. It is administered cautiously when indicated, e.g., for true anaphylaxis. Emergency physicians give epinephrine frequently, in many forms. Therefore, we have a better sense of the risks involved than many other physicians who very rarely or never use it in their daily practice. Our training includes the recognition that many medical errors involve doing too much rather than too little.
  • Injected epinephrine works within minutes, but lasts hours. This is important because it means that a patient can quickly get epinephrine if needed, but if given erroneously, the side effects don’t immediately go away.
  • Recent evidence from American emergency departments suggests that emergency physicians use epinephrine appropriately in 98% of cases.

These are points an emergency physician could have told a reporter in a few minutes over the phone. But a balanced story would have had a far less punchy headline and would not have gotten readers as excited and fearful or generated as much social media buzz. A nuanced view of the American Academy of Allergy, Asthma and Immunology’s joint task force recommendations on treating anaphylaxis in the emergency department would have been as interesting as it sounds. But a report about incompetent emergency physicians who deprive patients of the same medicine found in many mom’s purses gets readers to click, to “like,” to “share.” Winston Churchill remarked, “A lie gets halfway around the world before the truth has a chance to get its pants on,” and he said this well before digital reporting and social media accelerated the process.

This type of sensationalist medical reporting is both ethically questionable and potentially dangerous to the public’s health. It drives a wedge between patients and their doctors, focuses on perceived mistakes rather than on health outcomes (was anyone harmed by the supposed failure to give epinephrine?), and oversimplifies a complex health problem, encouraging patients to advocate unilaterally for a single treatment, an approach that rarely makes sense.

The media have an oversized impact on the public’s health concerns, the behavior of clinicians, and healthcare utilization. In 2009, the actress Natasha Richardson’s death from a head injury was associated with a two-fold increase in the use of head CT in a typical emergency department. We have experienced this phenomenon in our own practices, including demands from patients such as “I’m not leaving without a head CT,” even when established clinical rules tell us the CT is not indicated. This year, weary public health officials sent out repeated reminders that, despite the intense media coverage of Ebola, seasonal flu is a more imminent danger to US citizens.

A well-informed patient who has access to objective health information is a joy to treat. We’ve had patients present with flu-like symptoms and inform us that even though they received the flu vaccine, they know it was less effective this year, which is entirely true. In this way, journalism can play an important role in improving the general health-related knowledge, concerns, and behavior of the public. Conversely, a story that is written to alarm and disturb helps no one. And reporters are not the only ones to insert hyperbole into health news: research has found that universities themselves (whether the scientists or the public relations staff) are prone to exaggerating study findings.

How can a reader guard against this kind of health misinformation?

First, if it sounds too good or bad to be true, it probably is. Question the statement, click on the link, search elsewhere for confirmation.

Second, consider the information sources and persons being quoted. When deciding whether to try a new restaurant in town, you wouldn’t ask the owner of a competing restaurant what he thought of the food. You would consult a friend with similar tastes as yours who has eaten there before, or alternatively, an objective expert with experience in restaurants, like a food critic. Likewise, those best qualified to comment on American emergency medical practice are those who have actually spent time studying American emergency departments.

Third, ask your own questions. In this age of social media, we have direct access to people of all backgrounds. Within minutes of reading something that doesn’t make sense, you can get more information with the click of a mouse. Or, as most of our patients do, have a conversation with a reliable source.

Finally, when you see a story that falls short of your standards for responsible journalism, be sure to communicate this directly to the news organization. Even the best journalistic institutions sometimes get things wrong; the critical issue is how they respond to their mistake. Most organizations take seriously their responsibility to retract or correct unsubstantiated reports. Unfortunately, given the inherent difficulty of putting “the cat back in the bag,” erroneous stories often enjoy wide circulation long after they’ve been discredited, especially in the age of social media. It’s up to us to demand better reporting but also to help set the record straight. When your friends repost that same story a week later, let them know the truth.

The NPR article was right when it told patients to advocate for themselves. But it coaches poor advocacy skills while forgetting that physicians also advocate for them. We support health journalism that informs rather than needlessly frightens. And the next time one of us sees a person who actually needs epinephrine, we’ll be there in the middle of the night to give it; unless we’re in the next room over, having to explain to someone else why they don’t.

By: Esther Choo, Matthew Zuckerman Source

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