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.”