Discussion: bees

Last weekend at Pawtuckaway, there was an incident where an orienteer was stung by a bee and had a serious reaction. Fortunately, someone saw him in trouble and sent for help (what ensued is an entirely different, but interesting story). The thing is, although he was an adult, he evidently had no previous history of reactions to bee stings.

I'm guessing that whether or not you react severely to bee stings can change with age. Is there a test for this? It would probably be a good idea for us to occasionally check it out.

Note: I was stung by 4 bees simultaneously that day. Momentary pain, but that was it at the time. And heck, it was a good balance from the strained ligament on the other foot ;-) . A couple of days later I developed itchy red patches.

An athlete I know is severely allergic to bees, and carries a syringe with medication at all times while running outdoors.

As do Holger and Mike S - they have custom made holders for their EpiPens. Best not to take chances with one's life, no?

To see what can be done to identify and possibly quantify the reaction to bees (or other triggers), your best bet is to visit an allergist. Not sure what the setup is where you are, but around here we have a specially-trained family MD who can do much of the testing. It is also possible to do a desensitization injection series to help lower the severity of reaction.

Either way, people with identified severe allergies should carry their EpiPens EVERYWHERE. And a prudent meet organizer might ensure access to appropriate medications on a very rapid basis - sometimes even 15 minutes is not fast enough. I try to remember to at least bring benadryl with me to most O-meets, but don't have an EpiPen (nor do I have any serious allergies that I know of...).

And what is the "entirely different but interesting story"?

I was out in the woods at the time, but I believe it had something to do with every ambulance within 50 miles showing up.

I heard bits & pieces. Evidently the person who saw him emerged from the woods to find a ranger, who called the emergency in. Subsequently, hoopla ensued, and when Lex Bundschuh suggested that other orienteers were probably best able to find and bring the victim in, and that someone (herself, maybe?) was a trained physician and could treat him, she was brushed aside.

And, of course, paperwork was the natural consequence.
The bee-sting victim I gather is OK.

Another unrelated story that evoked emergency services.

For my 21st birthday I was given the awesome gift of a Ski trip to Alaska. I went up with a ski club that including my mother. Unfortunately, while i was there I tore my meniscus and had to take a day or two off the slopes (I skiied anyway, just a bit less). Normally that would be a horrible horrible thing on a ski trip, but I just discovered my newly aquired ability to enter bars! I spent a few nights bar'ing and in the process was picked up by a lovely native. Phone reception was terrible so the mom was unaware of my where abouts for a few days. (I know, terrible son, didn't call when I could). After I returned from my adventures in Anchorage (the skiing was in a town called Girdwood, 50 min away from anchorage) I was informed that I was a missing person who was thought to be a victim of exposure and bears.

Oops!
(I'd do it all again if I could though!)

All sounds vaguly familiar. I had 4 tendons severed in a canyoning accident. On the approach rather than in the canyon. Fellow canyoners walked out and summoned help. Help arrived with uniforms on. Told those who had done the summoning that they didn't need help to find me. Of course, they got lost andpolice appeared at midnight after being sensible and following those who knew where i was. The police apologised to me and said they'd be back to get me in the morning after they had found the official 'rescuers'.

Actually, when Sue came out of the woods, she ran into an orienteer (not a ranger) with a cell phone who called 911 while Sue continued back to the pavilion. Lex and 4 of us got the rough location, jumped into lex's van and drove to the nearest point and Lex stayed with the van while the 4 of us went in to search. We found the victim fairly quickly and I ran back to the road with the update while the other 3 began to slowly help the victim out. By the time I got back out to the road the circus had begun (police, ambulance, S&R etc) and none of them would listen to Lex when she explained that we had things under control - the victim was located, was with trained personell and headed out of the woods with assistance.

They took him to the hospital, but he was back on Sunday and appeared to be in OK shape, though I don't think he was planning on going back into the woods.

In regard to the original question, any person (child or adult) can develop an allergic reaction to bee stings at any time in their life after being stung at least once prior. The reaction is caused by the antibodies reacting to the sting and releasing chemicals and histamines into the body. Those are what causes the reaction (and why Benadryl, an antihistimine, is useful for treating smaller/localized reactions.) Obviously if someone knows they have a severe allergy, they will probably carry an Epi-pen, but there's always the first time.

I asked around about whether our club should stock an epi-pen in our first aid kits. Answer was not clear: apparently this could result in liability if we have it and don't use it or don't use it appropriately.

The Epi-Pens are meant to be self-administered ideally. They are prescribed to people with known severe allergic reactions, and should be replaced yearly or whenever they expire.

Around here, even the ER nurses and the lower-level EMTs cannot administer epinephrine, via EpiPen or otherwise, without an MD's orders - again due to liability issues. They can, however, offer the pen to someone who say, forgot their own pen or is having the effects of their initial dose wear off. And that's how I imagine a club pen being used.

The epinephrine doesn't last forever, and it is possible to require a second dose (I've often had to repeat doses in the ER). If you're way the heck out in the middle of nowhere, and/or the ambulance crew is lost, or whatever, it suddenly starts to make sense to have a pen available - or if you're lucky someone else with bad allergies is around and can lend you theirs....

And liability aside, wouldn't we rather have had a pen and been able to offer it to someone in need, rather than having had to watch them die because we were afraid to stock it in case of liability...?

For meets in and around the city, maybe it's not a big deal. But meets in remote areas do entail some extra risk. Having an EpiPen available is something that we could possibly do to lower the risks a little bit.

Wil, are there risks to the patient associated with administering epinephrine?

How would you get an EpiPen for a meet kit if they are under prescription?

So, on the literature I have in front of me regarding adverse reactions:

Serious reactions:
respiratory difficulty
arrhythmias
hypertension
angina
tissue necrosis

Common reactions:
palpitations
tachycardia
sweating
nausea/vomiting
pallor
dizziness
weakness
tremor
headache
apprehension
nervousness
anxiety

Basically most of the common ones seem to happen to some degree every time I give it, and I warn people accordingly. They're all about what you'd expect associated with a gush of adrenaline flowing through your system. In theory it's possible to trigger an angina attack due to vasospasm, particularly in a person with established ischemic heart disease (probably not too many of those floating around at orienteering meets...). Could also theoretically cause a stroke if accidentally injected into a vein - that's why the manufacturer advises injection into the thigh only.

Finally, I have also had people come to the ER after accidentally injecting the pen into their thumb/hand by holding it upside down, or else just playing with it.

The risks of epinephrine administration are potentially serious, but so are the risks of NOT using epinephrine if it's needed. Obviously one should go to the nearest ER immediately if an EpiPen has been administered.

The prescription medication could be obtained through your family MD - you'd have to explain why you felt it was warranted and convince them you knew what you were doing, but I guess most would oblige.

Wil - is Epinephrine really out of scope for ER nurses and EMTs in Ontario?? It's within our EMT scope (both Epi-pens, and the ambulances stock vials as well) in Alberta, as per offline medical protocols (although there have been some issues with the current EMT scope of practice, which are supposedly being worked out...). Not sure what the scope is like for PCPs in NS, but I guess I'll have to check that out soon!

For the ER nurses I guess it's a matter of hospital protocol. For the EMTs it depends on the level of training - and here they can't. Flight paramedics could do it, and maybe those with more training (usually working in larger centers). P2 or P3 I guess - not sure though.

There's certainly no magic to it, and if I'm going to be 10 minutes before getting there I'll often order it over the phone to save time - the nurses can give it then. Anaphylaxis can be scary stuff and epinephrine is clearly indicated in virtually every situation.

At Pawtuckaway, I believe there were two orienteers (one of them an MD) who had EpiPens because they are allergic to beestings, and they grabbed their EpiPens and headed out as part of the search. I also believe (though I'm not sure) that although the victim had exhibited alarming symptoms early on, that he had recovered enough by the time he was brought out of the woods that the epinephrine was not administered. The symptoms that he exhibited may not have actually been anaphylaxis, although there have certainly been occurrences of that at orienteering meets (including the two aforementioned orienteers).

So an adequate solution would be to have an orienteer who is an MD and allergic to beestings at our meets. With her Epi-Pen of course. Now there's a specific recruitment goal.

I have a good stock of Epi Pens, so if you need one let me know. I don't seem to need one these days as I have not had a reaction the last 10 wasp stings I've gotten. BTW Will, I attribute this to a doctor in Red Deer who gave me a massive amount of IV Benadryl after I was stung at the APOC in 2002(?). I also recieved an epiniphrine shot from an EMT at the finish area.
It was quite the zoo in the campground, but without the orienteerers, Jim wouldn't have gotten out of the woods soon.