Flying on Autopilot: Epinephrine Autoinjectors on the Radiologist’s Toolbelt
At the end of a long shift, are you ready to jump in and save a patient's life?
As the clock ticks down toward the end of a call shift, you plow through a stack of plain films that steadily increased as you diagnosed uncomplicated diverticulitis in the patient from the emergency department. The end is near; soon you will be out the door. Suddenly, the phone just inches away, piercingly shrieks, shattering the calm silence. Your technologist informs you a patient is reacting to a contrast bolus; he struggles to breathe. You franticly arrive at the gantry. Now what?
Each resident can attest to a similar scenario in his experience — naturally, occurring at an untimely moment. Often as radiologists, we labor to prove our value as physicians. Patients often are uninformed that radiologists are in fact doctors. After four years in medical school and twelve months of internship, we have earned our title as such. Yet as we tune our diagnostic skills, treatment often is learned incidentally. However, we are dutifully required on occasion to administer life-saving treatment in our department. After all, patients visit radiology expecting to leave no worse than how they arrived.
In a recent issue of the American Journal of Roentgenology, a group of investigators from Yale set out to measure the effectiveness of autoinjector epinephrine use in the radiology suite.1 The group cites a report demonstrating just half of radiologists know the proper dose of epinephrine to administer during anaphylaxis — a disheartening number to admit. Fewer of those could recall the proper route of administration. The group embarked on comparing the use of autoinjectors to that of traditional, syringe-based epinephrine.
The study included health professionals at all levels: residents, fellows, attendings, nurses, and mid-level providers. Any provider who could possibly respond to a contrast reaction participated. Timed scenarios in a clinical skills training environment were conducted with the use of medical-grade mannequins. Two scenarios and two intervention groups were arranged: moderate and severe contrast reactions, and manual and autoinjector groups. The outcome measured was total time to medication delivery and total errors between the groups. Participant surveys were distributed after each scenario to gauge participant comfort with the method of delivery.
There were several limitations to the study; all were addressed by the investigators. One area of concern involved the pre-scenario education on the autoinjector. All participants were instructed on how to use an autoinjector; none received training on manually preparing epinephrine from the vial nor was the appropriate dose reviewed. The team writes in response “we expected all health care providers to be comfortable with this action.” However, the investigators provided autoinjector training to all participants.
The results demonstrated less errors and more provider comfort in the autoinjector arm of the study, as expected. Time to administration was a little over one-minute faster in the autoinjector group as well. Also, about half of manual delivery test scenarios reported errors in dose and delivery method. More attendings comprised the autoinjector group; contrasted by more residents in the manual epinephrine group. However, the investigators assert through subgroup analysis the results are maintained.
As the on-call radiologist, our responsibility to patient care extends beyond diagnosis. At times, our skills as licensed physicians are called into action. From personal experience, my local policy on intravenous contrast reactions, as well as the ACR Manual on Contrast Media,2 are always on-hand in case a situation as above arises. Next time you are in the CT control room commiserating with the technologists; explore the contrast reaction kit. If your department does not stock autoinjectors, poll your fellow residents, and present a case to the chairman to invest in such a product. This may save a life; not to mention provide you piece of mind. Now head on home; your shift has ended.
By Michael Chorney, M.D., diagnostic radiology resident at University of Pennsylvania Hospital
1. Asch D, Pfeifer KE, Arango J, et al. Journal Club: Benefit of autoinjector for treatment of contrast reactions: comparsion of errors, administration times, and provider preferences. American Journal of Roentgenology. 2017; 209(2):W363–W369. DOI: 10.2214/AJR.16.17111.
2. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media. 2017, version 10.3. Available at https://www.acr.org/Quality-Safety/Resources/Contrast-Manual. Accessed October 2, 2017.