When a School Tries to Split Up Epinephrine Auto Injectors

Have you ever been in a situation where something comes out of nowhere and you are too surprised to react?  A parent recently shared an experience that had all of us in a private Facebook group for parents of children with food allergies up in arms.  I asked if I could share it here on their behalf to prepare others for questions that would otherwise catch them off guard.

To set the scene, imagine you are at your school’s “meet the teacher” night and dropping off medication, paperwork, and of course epinephrine auto-injectors:

“[They] promptly took out the [EpiPens] and split the two pack and handed one back to me. I kind of had a mini-meltdown […] I said what are you doing? You’re not supposed to split a two-pack. She told me that was [District] policy. She then checked with the nurse who said she’d been doing this for 17 (?) years and that they don’t ever keep the second one because, according to [District] policy, only a nurse is allowed to administer the second dose and that a nurse will almost never be on campus. I was a little shocked and replied that I was told NEVER to split the two-pack. They told me they could keep the second one, if I insisted. They told me they had been splitting the two-packs all morning and I was the only one who said something. […] This was new to me as last year they took the two-pack, no problem.”

The parent here, let’s call them Pat, is entirely correct.  Epinephrine auto-injectors come in packs of two for very specific reasons.  In researching for this post, I stumbled upon a 2008 post from “Our Story: The Good, the Bad, and the Food Allergies” by Janeen Zumerling where she discussed being faced with a pharmacy trying to fill one prescription for a 2 pack of EpiPens instead of more because they figured two pens came in one box.  So while this is the first time I’ve heard personally about this happening, it could happen at school, at the pharmacy, or elsewhere.

Suggestions as to How to Respond

(The following come with the overall caution to remain respectful, polite, and evidence based in your appeals to the decision maker in question – it may also not be a good idea to have these discussions in front of your child, depending on their age, if they are present when the attempt to split injectors occurs):

1) “This is how my doctor prescribed it.”

Sometimes people will back off if you tell them the instruction comes from someone other than yourself, like an allergist or physician.  My daughter’s allergist writes her prescription for a “two pack” – does yours?  In the story above, Pat was told that the school nurse had been doing it this way for years and that no one else had complained, so this response may not work.

2) Stock Epinephrine Laws

If your state has a stock epinephrine bill, as Nevada does, you can point to the bill’s language.  Nevada specifically references “two doses” of injectable epinephrine.  NRS 388.424 (I’m so used to calling it Senate Bill 453, I had to look up the final Nevada Revised Statutes citation, it makes me happy to see it nestled in the law on the legislature’s website!) reads (in part) as follows:

Each public school, including, without limitation, each charter school, shall obtain an order from a physician or osteopathic physician for auto-injectable epinephrine pursuant to NRS 630.374 or 633.707 and acquire at least two doses of the medication to be maintained at the school. If a dose of auto-injectable epinephrine maintained by the public school is used or expires, the public school shall ensure that at least two doses of the medication are available at the school and obtain additional doses to replace the used or expired doses if necessary. 

(emphasis added).

3) Clarify – EpiPen and Auvi-Q versus Twinject

If your injector is the Auvi-Q or EpiPen, that the Twinject is the only injector where the first dose of epinephrine is an autoinjector and the second is a traditional injection that might cause the concern regarding a nurse administering it.  (Source)  Even so, the doses should be kept together.

4) Look into self-carrying

If your child is responsible, they may be able to carry both doses on their person instead of having to wrangle a school when it comes to attempts to split doses.

5) Turn to your 504 Plan (or IEP)

Depending on the makeup of your school (public schools fall under this, for example, it is dependent largely on the receipt of federal money), you may qualify for a “504 Plan” for your student.  (Source, I discussed school accommodations in my overview of the Fox Chapel case FARE amicus brief as well.)  This is a shorthand reference to the accommodation to which you are entitled for your student.  Don’t have one?  Request a meeting.  Even if the person trying to split your injectors is a novice on the food allergy front, they should know what a 504 plan is (stay tuned for a post on what to do when you get blank stares after mentioning it, as happened to a friend of mine recently).  Does your plan reference both doses?  The plan we have for my daughter references a second dose after 10 minutes if emergency services have not yet arrived.  Some schools may not permit a 504 plan where an IEP (Individualized Education Plan) is in place to cover other accommodations, so your allergy procedures should be contained in that document instead.

6)  Go higher up

You can speak to someone in the school district that may be more informed than the individual you’re dealing with.  If the person you’re facing is a school nurse, use data from the National Association of School Nurses.  They have a great guide about anaphylaxis here (aptly titled “Saving Lives at School“) and I’ve isolated the page about two doses of epinephrine below (click the image for a larger version).

Second Dose of Epinephrine Referenced in School Nurse Guidelines
Second Dose of Epinephrine Referenced in School Nurse Guidelines

7) Research Response Times

This may take some google searching on your part but some areas may have response times for emergency services (ie, 9-1-1) that exceed 5-10 minutes.  If you’ve ever been in a traffic jam near your child’s school, you probably won’t be surprised when you do find the stats you need.  You’ll see that this is even more important when you see my notes on biphasic reactions below.

8) Know Some of the Reasons Why Epinephrine Autoinjectors Come With Two Doses

Not only could the first injector malfunction, there may be user error (or inexperience) at play in addition to the risk of biphasic (subsequent) reactions from the same exposure or the epinephrine wearing off before help can arrive.  I’ve broken this final suggestion down with supporting information I was able to find – sometimes just knowing why a protocol is in place will help you if someone down the line challenges you.

Background Research

Here is some additional information (background research that I did) that could come in handy if someone tries to force split your two pack of injectors:

A second Dose of epinephrine is required For At Least 1 in 10 patients

While the percentages vary, a second dose is required for 10%-35% of patients experiencing an allergic emergency to deal with the symptoms of the reaction.  (EpiPen says 20%, Auvi-Q says 10%-20%, and Twinject says 35%)  Remember, of course, I am not a physician and none of this is a substitute for medical advice.  I just want to arm people with information that they could use if they find themselves in Pat’s shoes.  A study spanning 2001-2006 records for two hospitals in Boston found that 12% of children required two doses of epinephrine as opposed to one per Susan Rudders, MD, of Children’s Hospital Boston. (Source:  “Kids With Food Allergies May Need 2 EpiPens” – WebMD Health News, March 26, 2010)  The article goes on to quote Dr. Rudders as saying, “The problem is, we really don’t have good ways of identifying who will and will not need an extra dose.”

The effects of one dose of epinephrine may wear off after 10-20 minutes

Epinephrine suppresses the progression of a reaction. (Source)  It may wear off after 10-20 minutes, however, which may not be enough time for emergency help to have arrived.  (Source)  Remember, use epinephrine by injecting it into the outer thigh, call 911, also remembering to keep the patient lying down with their feet elevated and be prepared to use that second dose.

User Error And Device Malfunction

 Not that anyone wants to consider making a mistake when the situation calls for epinephrine, but in a high stress situation the person using the product may not know how or may make a mistake.  I found an interesting article from 2010 that compared four injectors (it was funded by the makers of the Intelliject, later called the Allerject in Canada or Auvi-Q in the United States) entitled: “A comparison of 4 epinephrine autoinjector delivery systems: usability and patient preference” from the Annals of Allergy, Asthma & Immunology (by Stephanie Guerlain, PhDemail, Akilah Hugine, MS, Lu Wang, MS, in Volume 104, Issue 2, Pages 172–177, February 2010 – the manuscript version is here).

The manuscript mentions that when a device malfunctioned, the likelihood of failing to follow instructions was higher.  What I was searching for were stats on malfunction but the reference here admits it is a possibility in a test setting at least:  “Studies have shown that patients and caregivers do not always correctly administer epinephrine autoinjector devices. […] There may also be a large time lapse (several years) between when a person is trained on an autoinjector and when it must be used during an allergic reaction. Finally, a patient or care provider may be under significant stress while attempting to provide the potentially life-saving dose of epinephrine when it is used.”  Id.

As an aside, I was surprised that the most common error for use of an epinephrine injector was not holding it for the correct amount of time.  In the study I looked at,  versions of what would become the Auvi-Q (INT02 and INT01 in the study)  were used as well as the EpiPen and the TwinJect.  “The INT02 device resulted in participants committing this [(not holding long enough)] error 11 times compared with 27 (INT01), 40 (EpiPen), and 42 (TwinJect) times.”  Training across devices was held to be crucial, with the manuscript indicating that “[t]he fact that less than 50% of participants across all devices could follow the labeled instructions without committing a single error provides confirmation that the need for training on the use of epinephrine autoinjectors is still important.”

I didn’t mean to get sidetracked but I found it interesting.  At any rate, someone administering the medicine could not hold it long enough, the device itself could malfunction, the person may not be adequately trained, or the stress of the situation could cause errors as well.  With these things in mind, a second device is a very important thing to have.

Biphasic Reactions

The first time I heard of biphasic reactions I was fairly shaken.  It isn’t enough to worry about accidental exposure to an allergen without now thinking that you could have the reaction, be stabilized, only to have it return like an aftershock even hours later.  A biphasic reaction is defined as “a worsening of symptoms requiring new therapy after resolution of anaphylaxis.”  (Source)  (This Post Updated 12/1/14 to include this post by Dr. Anne Ellis about Biphasic Reactions: “Biphasic Anaphylaxis: What You Should Know“)

Final Notes

I hope some or all of the above is useful!  I also hope you don’t run into push back when you work with your school.  Pat was able to get the school to retain both EpiPens and I really appreciate the talking point the story provided (thank you!).

As I stated in my post regarding EpiPen and Auvi-Q expiration dates (people are reporting in the comments that they’re receiving their $400 Auvi-Q savings cards in the mail in about 2 weeks after reporting short dated injectors, check out Amazing & Atopic and Food Allergy Pharmacist for even more if you’re following the issue), I have connections at both Mylan and Sanofi (I am the co-founder of the Food Allergy Bloggers Conference and they are both sponsors and my travel, hotel, and some food was covered for my attendance at the Mylan Summit earlier this year) – see my disclosures page as always for more.

The opinions herein are my own, do not constitute legal advice or medical advice, and are provided merely as discussion points.  I am an attorney and parent of a child with food allergies living in Southern Nevada. 

27 thoughts on “When a School Tries to Split Up Epinephrine Auto Injectors

  1. Policy at our school (IL) dictates that any medications left at school to be administered by staff must have either a doctor’s written notice (for OTC meds) or be in the original packaging with the prescription label intact. That being said, every year the school has asked us if we want to keep the second injector to make sure we have one at home. Then they take out the practice dummy and return it (they have several for each type already) and happily stash away our meds in a LOCKED cabinet. This is also policy for all prescription meds (they don’t want other students accessing any of the meds should the nurse be out of the room). In the past two years, the extra few seconds that it would take the nurse to unlock the cabinet and get to my son was not an issue as his classrooms were literally right next door and across the hall. This year, his classroom is down the hall at the other end of the building. To her credit, on the first day of school, the nurse suggested having a 504 meeting, and asked if it would be appropriate for my son to self-carry. Policy states that any meds placed in school responsibility must be under lock and key, so even if his teacher holds it, it must be kept in a lock box. We have our meeting in a week, and will have to go back to our doctor to get written authorization for self-carry, but I am encouraged that my school is being so proactive. I wonder, though, if it is the school, or just our nurse – her daughter is anaphylactic to fresh garlic! Thank you for providing a voice and a forum for all of these issues, Homa!

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    1. Your mention about the original packaging is important – I used to throw mine away but came up against that request when my daughter was in preschool. Makes me think the companies should package them in carriers! The locked cabinet issue is huge, and considering IL is on the forefront of so many food allergy issues I’m really surprised that it is their policy. Self-carry is certainly the way to go in that situation! I am lucky my kiddo is really responsible and doesn’t play with them but I know some school officials have the worry that other students will access the medicine and fiddle with it. Ideally there’s going to be supervision at most points in a day and that sort of behavior wouldn’t get far. Thank you for reading and commenting! I really appreciate the insight into what is going on across the US!

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    1. That certainly makes me worry if allergists aren’t educating patients enough to make sure they carry both injectors! And thank you for your kind words, Selena!

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  2. Homa, Brilliant blog post. I am asking my readers on Wednesday to read this. I appreciate your homework on providing the reasons of why not breaking up the two pack is key. Of course, I adore that you provided vetted stats!

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    1. Thank you, Caroline! I really appreciate the support and share – I think sometimes we are so entrenched in food allergy management that we forget that the reason we reached out to find information online was because we weren’t getting education from physicians. Others are in the same boat, it seems. I hope this helps even one person!

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  3. It is a good thing that the school kept both pens. However, if the nurse is the only person that is allowed to administer the second dose and the nurse is rarely on campus then, IMHO, the issue is not solved. In my view, the school has appeased the mother by allowing the second dose to stay on campus but really has no intention of using the dose. The problem might be better addressed by the school board, district school nurse supervisor, and possibly the state legislature. It’s beyond scary to think that a teacher or other staff member may not administer the second dose (if needed) due to fear of job loss and legal repercussions. Perhaps my concerns are a bit cryptic but similar things have happened. The policy behind the school not wanting to keep the second dose is more problematic than just simply not keeping the second pen.

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    1. Thank you for commenting, Tiffany! In this particular case we have no limitations in Nevada on who can give a second dose for an auto-injector that I am aware of. I will have to find out if there are states where there is that restriction, but the only situation so far I’ve seen is the Twinject where the second dose is an actual manual injection. For Nevada, it is actually against policy to split up injectors, so hopefully the misinformation can be corrected!

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      1. Thank you! I think it goes back to being fearful about liability, but with the right framework you can balance the risks to the person administering the injection and the one receiving it. I think there’s some overlap with other situations where injections come into play, such as for diabetics. I am not terribly informed on that front but it might explain the application of a prior policy about insulin injections would perhaps limit the way epinephrine injections are handled.

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  4. Update on our 504 meeting – We met with the school officials. Our son now has a second set (4 total doses) of Auvi-Q’s at school – one set in the nurse’s office and a second set that will be stored in his teacher’s Emergency Evacuation backpack. That way, he has a set in his classroom, should there ever be a problem, and the teacher will have a set on hand should the school ever need to be evacuated for any reason. Interestingly, the only person in our meeting (besides us) that knew that a second dose might need to be administered before emergency personnel arrived on scene was our school nurse, who is herself an allergy parent!

    While we were in the meeting, I also delivered several copies of the FARE Teal Pumpkin Project posters to be put up around school. Another thing the school officials were not aware of! My advocacy quest continues! Thanks again, Homa, for such a wonderful forum for our community!

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    1. I am so glad that there are backups for your son – it is such a simple thing that can have life saving implications for other children as well. Isn’t the Teal Pumpkin Project great? I think the fact that it has a celebratory element that goes beyond the food allergy community is making for a wonderful message. It says “you are welcome here.” I love that you shared it with your school! Keep advocating and thank you for your kind words!

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