Imagine this scenario: A fourteen year-old boy is enjoying his first river trip with his family. He’s playing on the beach when he gets stung by a scorpion, and within mere minutes it’s clear that he is experiencing anaphylaxis-a severe allergic reaction. The boy is having trouble breathing, and his mucus production is so severe that the guides need to position him so that his lungs don’t fill up with it. The trip leader has received anaphylaxis training from his Wilderness First Responder course and recognizes the symptoms. Fortunately he carries injectable epinephrine and Benadryl in his first aid kit and uses them on the boy. The symptoms abate briefly only to return. The guide injects another epinephrine dose with no effect. He does so again and again, hoping they’ll have enough to keep him alive until the Benadryl can work. After several tense hours, the boy stabilizes and the crisis is over. A life is saved. This is not a fictionalized account of what could happen. This frightening story is absolutely true. It occurred on a commercial river trip through Grand Canyon a few years ago, and it could happen again, at any time, and always without warning-a life and death situation. Which leads us to the very important article below.

ver the past year and a half, Grand Canyon River Guides has been exploring the legal conundrums posed by the lack of medical control for commercial river guides when using their Wilderness First Responder training in Grand Canyon. In doing so, we found that the discussion was most often framed in terms of the administration of epinephrine to treat severe allergic reactions. River guides are trained to recognize and treat anaphylaxis, yet it is illegal to do so in the state of Arizona without a written medical protocol provided by an advising physician or direct medical supervision in the form of radio or telephone contact by a supervising medical facility. The use of epinephrine therefore, appears to be the “boogey man”-the life and death situation that strikes at the heart of the issue that drives liability concerns for river guides and outfitters alike.

Our discussions about the medical control issue, whether at gcrg’s 2004 Fall Meeting or through the Boatman’s Quarterly Review, have been designed to inform and to stimulate discussion. Concern about the issue was so great for azra guide Kevin Greif, that he conducted his own research and subsequently discovered an Oregon state law that allows certain individuals (camp counselors, teachers, daycare providers, etc...) to be trained in the proper administration of epinephrine, to obtain a prescription, and to use it in case of an emergency when medical help is not readily available. Further investigation revealed that a few other states have similar laws. The important point here is that legal precedence exists. In fact, twenty years ago, the American Medical Association felt so strongly about the issue that they drafted model legislation for “An Act Relating to Administration of Epinephrine by Certified Laypersons in an Emergency Situation Caused by Insect Stings.”

But what would this mean for river guides? Beyond legalization, such a law would also clearly define and standardize training protocols. Most Wilderness First Responder classes already include an “epi” training section, which could hopefully serve as the logical venue for standardized training that would be both acceptable to and in accordance with state regulations. Ideally, efforts would be made to ensure that any “epi course” would be user-friendly for river guides, with little or no cost, and readily available at numerous times of the year. In other words, guides would be afforded the significant benefit of being well-trained and legally protected when acting to save a life, yet with (hopefully) few bureaucratic hassles. Physicians with a strong association to the river community such as Dr Walt Taylor, Dr. Tom Myers, and Dr. Michelle Grua, concur that pursuing a similar law for Arizona is absolutely necessary to successfully address this potentially fatal medical emergency. In fact, according to Dr. Taylor’s frank observation, “It’s just unthinkable not to clarify this issue by making it legal.” Dr. Grua felt so compelled to act that she took it upon herself to initiate preliminary contact with Arizona state representative Doug Quelland, Chairman of the House Health Committee, to gauge his support for such legislative action. She did so not as a representative of gcrg, but rather as a member of the river community at large, as a physician with Grand Canyon ties, and as a concerned individual. Representative Quelland, having suffered an anaphylactic reaction himself, has a unique understanding of the requisite timeliness of the administration of epinephrine.

The latest response received by Michelle Grua on October 30th, indicated that he had forwarded the information on the Oregon epi law to the legislative council, and would have a first draft within a week. Representative Quelland will be sending Michelle a copy of that draft for review. We will also request that both gcrg and the Grand Canyon River Outfitters Association be afforded the opportunity to review the draft legislation as well, with an eye to what is necessary and appropriate for our industry. Momentum is rapidly building and it behooves us to be involved in the process as it moves forward. Obviously, this topic is one that elicits strong feelings. But for every action, there is a reaction-some guides may feel just as strongly that the epinephrine question should not be legislated, institutionalized and standardized.

The Board of Directors of Grand Canyon River Guides, mirroring these divergent opinions, is somewhat split on this issue as well. Some board members feel that Arizona legislation regarding the administration of epinephrine should be actively pursued. Others caution that it should remain a “gray area” and feel that one more certification might be too much of a burden on guides who are already overwhelmed by the extensive requirements of Grand Canyon National Park. All have valid viewpoints. However, we can agree about the importance of broadening the discussion beyond the board itself, by presenting the issue publicly through this newsletter.

Epinephrine legislation is undoubtedly an important issue that requires all sides of the issue to be evaluated equally and rationally.Towards this end, we have provided below a few relevant questions and answers that may impart a bit more clarity, or at least food for thought:

How much of a problem is anaphylaxis?

For answers, we turned to a document developed by the Oregon Department of Human Services document, entitled: Treatment of Severe Allergic Reaction: a Protocol for Training, Revised 1/02. It is estimated that one to two in every 100 people area risk for a severe allergic reaction to food, insect stings, medications or latex.
Severe life threatening allergic response to various allergens occurs in only a small percentage of the general population [Grabenstein, Smith, 1989]. However, when they occur, immediate administration of injectable epinephrine is vital. A systemic reaction to an insect sting, for example usually occurs quickly; death has been reported to occur within minutes of a sting [Stinging Insect Allergy, 1981]. To compound the situation, the person suffering the allergic response is often unable to self-administer his/her injection or has no previous history of allergic responses and is unequipped for the situation.

Anaphylaxis training was part of my wfr course, and I even have an anaphylaxis card from Wilderness Medical Associates. Aren’t I already legally covered?
If you read the fine print on the back of your anaphylaxis card, you’ll notice that it states, “Use of these skills must be approved by a physician advisor or medical control.” The protocols for the administration of injectable epinephrine require medical control which is generally not available in Grand Canyon unless you happen to work for the nps or one of the very few outfitters that have a consulting physician licensed in Arizona (most don’t). Therefore, do not assume that your first aid training legally allows you to perform everything you’ve learned, because that is simply not the case.

If I get a prescription for epinephrine from a doctor, isn’t that considered medical control?

No, it isn’t. Legally speaking, prescriptions are only for the use of the person who has been prescribed the medication. In fact, using a prescription belonging to someone else is considered a felony. A more accurate term for medical control is really “consulting physician.” This implies that the consultation is occurring (either in person or by phone) at the time of the medical emergency based on their understanding of the situation, the patient’s symptoms, etc...

Aren’t I covered by Good Samaritan Laws?

Good Samaritan laws for the use of injectable epinephrine exist in Utah and Oregon. As a working river guide in this state, Good Samaritan statutes may not apply since Grand Canyon National Park requires you to have this training and you are paid to do the job. Arizona State Revised Statutes define a Good Samaritan as “a person who renders emergency care or assistance in good faith and without compensation at the scene of an accident, fire or other life-threatening emergency and who believes that a significant exposure risk occurred while the person rendered care or assistance.”

How would I be protected by a state law?

As an example, the Oregon law as it applies to anaphylaxis includes a clause regarding immunity for trained persons rendering emergency assistance. This clause specifies that there is no cause of action against a person who has successfully completed an educational training program described in the law “for any act or omission of the person when acting in good faith, except where such conduct can be described as wanton misconduct.” The same is true for the institutions, facilities, agencies or organizations that allow for the rendering of this emergency treatment.

We ask that you carefully ponder the information presented here. Talk to your fellow guides and to your outfitters. Search your own feelings. This boils down to an incredibly important question-should we (the commercial river running industry) support the passage of legislation that legalizes the administration of epinephrine in situations where a licensed health care professional is not immediately available? Please provide gcrg with your thoughts on the matter by phone, letter, or email to gcrg PO Box 1934, Flagstaff, az 86002, (928) 773-1075, gcrg@infomagic.net.

Lynn Hamilton
Executive Director gcrg