Two boxes of EpiPen epinephrine auto-injectors

Credit: Bioridge Pharma

Epi-Pen epinephrine auto-injectors in adult and junior sizes.

When a Murietta Valley Unified School District elementary student bit into a cupcake made with peanut butter in April, she quickly struggled to breathe. A school health aide grabbed a pre-loaded syringe of adrenaline from the supply cabinet, injected the girl and contained her allergic reaction until she got to the emergency room, exactly as a new California law intended – but not, in fact, how the law is playing out in many districts.

Six months after the Jan. 1 law required schools to stock these pre-loaded syringes – known as epinephrine automatic injectors and considered the first line of treatment for potentially life-threatening allergic reactions – many districts have been unable to obtain what Murietta Unified has: a doctor’s prescription for the devices.

Up and down the state, doctors have declined to write prescriptions for epinephrine auto-injectors for districts, citing liability concerns and derailing the promise of the law. A February survey of 408 school nurses by the California School Nurses Organization found that 57 percent had been unable to obtain epinephrine auto-injectors for their district, calling the inability to find a doctor to write a prescription a major obstacle.

“The law indemnified everybody except the doctor,” said Dr. Brett Curtis, a consulting physician for the Oakland Unified School District.

Many districts have turned to city and county public health doctors as the logical prescription writers, only to be rebuffed. “They are being asked to sign these orders, but are being told by their county counsel and their risk managers that the liability risks are real,” said Kat DeBurgh, executive director of the Health Officers Association of California, a Sacramento-based membership group for city and county public health doctors.

The impasse has prompted the author of the law, state Sen. Robert Huff, R-Diamond Bar, to introduce follow-up legislation designed to protect physicians from prosecution if they write these prescriptions. The bill, Senate Bill 738, passed the Senate this month and is in the Assembly.

Dr. Brett Curtis, a consulting physician for the Oakland Unified School District, is all for it. “The standard is to prescribe on the basis of a good-faith exam,” he said. But the law asks doctors to write a prescription naming the school district as the patient, with the injectors to be used to treat a student or adult as needed – which means “a patient I’ve never seen,” Curtis said.

“The law indemnified everybody except the doctor,” he said.

His medical liability insurance company agreed. In order to write a prescription to bring Oakland Unified into compliance with the new law, Curtis took out additional liability insurance. Now he writes prescriptions for stock epinephrine auto-injectors for all 86 schools in Oakland.

About 8 percent of children nationwide have food allergies, according to a 2011 article in the journal Pediatrics, and of those, nearly 40 percent have had a severe reaction known as anaphylaxis, where blood pressure drops and airways constrict. Other symptoms include hives, a swollen tongue and vomiting.

Severe food allergies have become an issue in schools across the state and the nation as the percentage of children who are allergic to nuts, milk, wheat and other substances has increased, according to the Centers for Disease Control and Prevention, for reasons researchers can’t definitively explain.

Some schools have introduced nut-free zones in school cafeterias and ingredient inspections for classroom birthday treats. But enforcement can be difficult.

For instance, just days before the Murietta Valley student took a bite of the peanut butter-filled cupcake, Cathy Owens, a school nurse and coordinator of student support for the district, sent a memo to teachers stating that parents must give advance permission for their child to eat food brought in for school events. But at the classroom cupcake party, that notification never happened, Owens said.

The result is a lot of anxiety for parents and for school nurses like Martha Wallis, who said she has given at least four emergency epinephrine injections in the past five years in the unified districts of Moreno Valley and Lake Elsinore. A local physician was willing to write a prescription for stock epinephrine even before the law required schools to have it, she said.

One injection was for a high school boy who had a serious reaction to a bee sting, although he didn’t know he was allergic to bee venom. Another was for a kindergarten girl with a known allergy to peanut butter who didn’t recognize the circle-shaped peanut butter sandwich in the cafeteria as a peanut butter sandwich – Wallis used the girl’s own EpiPen, a brand of injector, to give her a shot of epinephrine.

A third case involved a 4th-grade boy who couldn’t stop vomiting after eating peanut M & Ms last fall, although he had no known allergy to peanuts. And a fourth case concerned a teacher who ate mango flavored yogurt and experienced the swollen tongue and constricted throat of a serious allergic reaction, Wallis said.

While many students with severe allergies carry their own epinephrine auto-injectors or keep one at the school office, others don’t. And 20 percent of severe allergic reactions at school happen to children who have never been diagnosed with a severe allergy, said Dr. Marc Lerner, medical officer for the Orange County Department of Education.

As a school district employee, Lerner says he is covered by the district’s risk insurance. So he’s written prescriptions for epinephrine auto-injectors for 600 schools in 28 districts in Orange County, using the website EpiPen4Schools.com, which offers free and reduced-price epinephrine auto-injectors to schools across the country.

Lerner is one of a group of doctors who have stepped up to write prescriptions for districts. Others are Dr. Timothy Mackey of Riverside, who prescribes for Murietta Valley Unified, Dr. Howard Taras in San Diego and Dr. Travis Miller in Sacramento.

Miller, a board member of the California Society of Allergy, Asthma and Immunology, testified in favor of both the current law and the follow-up legislation and said 10 members of the allergist group expressed concern to him about liability. But epinephrine is not considered a particularly dangerous medication – it is adrenaline, and receiving a shot unnecessarily will cause a rapid heartbeat, but has never been reported to cause death, he said.

So he prescribes for Rocklin Unified School District, Auburn Union School District and others. “I’d rather sit on the right side of health care,” he said.

At a hearing of the state Senate Judiciary Committee earlier this month, school nurse Melissa Locketz urged passage of the new legislation to dispatch physicians’ liability worries. She read five statements from fellow school nurses, including this one: “It does not seem fair that some schools are lucky to have relationships with physicians, while others can’t comply because no one will sign.”


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  1. Kevin Gates 10 months ago10 months ago

    Such school casualties must be handled with great precautions! Awareness programs are the key helpers. Jurisdiction has the responsibility and we appreciate their unfolded laws that seem to be very helpful.

  2. Marsha Oilar, R.N. 1 year ago1 year ago

    I am a 38 year nurse and currently am the corporation nurse for North White Schools. Previously, I had been a school nurse for Delphi Schools and had a 6th grade student in full-blown anaphylaxis. Both schools are rural, located 15 miles from the nearest hospital. This student had no previous history. She presented with B/P 60/0, HR 160, severe respiratory distress with impending failure. Of course she had no EpiPen … Read More

    I am a 38 year nurse and currently am the corporation nurse for North White Schools. Previously, I had been a school nurse for Delphi Schools and had a 6th grade student in full-blown anaphylaxis. Both schools are rural, located 15 miles from the nearest hospital. This student had no previous history. She presented with B/P 60/0, HR 160, severe respiratory distress with impending failure. Of course she had no EpiPen available to her. I had to use another student’s beesting kit to save her. Thankfully, I was not at my other rural school at the time of the incident. Previously, I had begged to stock Epi in each health room, but my request was declined by our county health officer. The reasoning, “You can’t give it without an order.”
    After the above incident, this same county health officer honored my request immediately. This happened in 1994, before the Epi-Pen for Schools program was initiated.

    Replies

    • Jane Meredith Adams 1 year ago1 year ago

      What a close call.

  3. Debra Johnston 1 year ago1 year ago

    I agree that new legislation to indemnify health care providers (MD, DO, PA, NP) who write prescriptions for stock Epinephrine auto injections is warranted.

    I would also like to see that legislation include allowance of stock Epi on field trips.
    My students go on field trips in rural/foothill regions sometimes overnight. I would sleep much better knowing that there is Epi available on the field trip,in case of emergency, while students/staff are in remote areas with spotty or no cell phone reception.

  4. Andrew 1 year ago1 year ago

    The actual incidence of fatal anaphylaxis in the US should be kept in perspective. One large study in the Journal of Clinical Immunology (2014) concluded that there were 2458 cases of fatal anaphylaxis in the US over a 12 year period. But of these only 6.7% arose from food (most arose from drugs, including chemotherapy, many in a hospital setting). Of the 6.7% which arose from food, the most arose … Read More

    The actual incidence of fatal anaphylaxis in the US should be kept in perspective. One large study in the Journal of Clinical Immunology (2014) concluded that there were 2458 cases of fatal anaphylaxis in the US over a 12 year period. But of these only 6.7% arose from food (most arose from drugs, including chemotherapy, many in a hospital setting). Of the 6.7% which arose from food, the most arose in adults. Doing the math would suggest that something fewer than 12 children die per year in the entire US from food induced anaphylaxis. There are about 70,000 public schools in the nation. Not all food induced anaphylaxis, when it occurs in children, occurs in school. Doing more math will suggest that in any given year, approximately one school in 5,000 had a student who died of food induced anaphylaxis, in or out of school. Applying the math to California alone, the stats suggest that maybe one student dies a year in the entire state of 40 million or so from food induced anaphylaxis, in or out of school. These stats predate the movement to insist on Epi-Pens at schools.

    Supporters of the law reported the 2013 death of a Sacramento area girl from peanut allergy induced anaphylaxis at a relatively remote camp. But in that instance, her father was a physician and was present, administered injected epinephrine via Epi-Pen, and despite his expert and heroic measures was unable to prevent the fatality.

    This is not to trivialize anaphylaxis or the need for appropriate intervention when it occurs. But anaphylaxis deaths still occur mostly in hospital settings from medications where there is plenty of epinephrine on hand and lots of trained personnel.

    With these things in mind, I found myself in agreement with the CTA in opposing mandatory vs. voluntary Epi-Pens at schools. Teachers will doubtless be strong-armed into getting trained as medical personnel in the hope that they will become experts at diagnosing anaphylaxis and administering epinephrine to address a tiny statistical mortality risk. Why not, we expect them to do and be everything else?

    What personnel would be appropriate to determine whether a student actually had dangerous anaphylaxis and whether emergency epinephrine should be administered prior to the arrival of medical first responders? School nurses. But California only has one school nurse for every 2,850 students, compared to the national average of one for every 1,100 students and the state of Vermont with one for every 275 students.

    Given the statistical rarity of death in children from anaphylaxis, perhaps we can predict that more teachers will die in auto accidents on the way to anaphylaxis training than students are saved by teachers with Epi-Pens. The function is one really calling for school nurses. Why doesn’t the legislature require a trained nurse to be present at every school and pay for it? But making an unfunded mandate to have Epi-Pens and trained personnel on hand at every school costs the CA legislature nothing and makes for good press.

    Replies

    • CarolineSF 1 year ago1 year ago

      Not just teachers, but school secretaries and subs and whatever other adult is handy. This story doesn't go into the complexity that many (most?) California schools have no such thing as a school nurse or school health aide around all the time. So the reality is that some random adult with as much health training as I have (a CPR course or two at some point) or you, whoever's reading this, or you, EdSource writer … Read More

      Not just teachers, but school secretaries and subs and whatever other adult is handy. This story doesn’t go into the complexity that many (most?) California schools have no such thing as a school nurse or school health aide around all the time. So the reality is that some random adult with as much health training as I have (a CPR course or two at some point) or you, whoever’s reading this, or you, EdSource writer or editor, would be the one called upon to make a decision and administer that injection. Everyone feel confident about that situation?

      • Jane Meredith Adams 1 year ago1 year ago

        Hi Caroline.
        You’re exactly right that most schools don’t have a school nurse or health aide around all the time. And no doubt, a nurse or health aide would be the best person to make the decision to give an injection. In my reporting I was told that many schools already have a student who carries an EpiPen and a staff member who has been trained to use it.

        • CarolineSF 1 year ago1 year ago

          But then in these cases described in the article, the person I accurately describe as a "random adult" would be expected to make medical diagnoses and treatment decisions, right? "One injection was for a high school boy who had a serious reaction to a bee sting, although he didn’t know he was allergic to bee venom. ... A third case involved a 4th-grade boy who couldn’t stop vomiting after eating peanut M & Ms … Read More

          But then in these cases described in the article, the person I accurately describe as a “random adult” would be expected to make medical diagnoses and treatment decisions, right? “One injection was for a high school boy who had a serious reaction to a bee sting, although he didn’t know he was allergic to bee venom. … A third case involved a 4th-grade boy who couldn’t stop vomiting after eating peanut M & Ms last fall, although he had no known allergy to peanuts.”

          Again, when no nurse is on hand, as is far likelier to be the case, even with one adult on campus trained to administer an Epi-Pen to a child with a known allergy, in other cases (repeating myself): “Some random adult with as much health training as I have (a CPR course or two at some point) or you, whoever’s reading this, or you, EdSource writer or editor, would be the one called upon to make a decision and administer that injection. Everyone feel confident about that situation?”

          I’m belaboring this point because I think it’s being downplayed or overlooked in the coverage and the discussion. We’ve shrugged off the fact that school nurses have become rare, and we’re putting expectations on whatever adult happens to be around to make medical judgments and administer treatment in potentially life-threatening situations — we’re not talking about a band-aid on an owie. Should this be emphasized more clearly and called out more strongly? (Rhetorical question.)

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