By Dr. Paul Ehrlich
George Bernard Shaw said that England and the United States were two countries separated by a common language. The same can sometimes be said of doctors in different medical specialties. In the March issue of the Journal of Allergy and Clinical Immunology, Dr. Carlos Camargo considers the gap between allergists and emergency department doctors in an editorial entitled “Potter Stewart and the definition of anaphylaxis”. The title refers to Supreme Court Justice Potter Stewart’s criterion for hard-core porn: “I know it when I see it.” He says:
I heard that quote many times when I began clinical research on food allergy and asked my allergist/immunologist colleagues about their definitions of anaphylaxis. I complained that allergy textbooks offered definitions based on IgE levels, mast cells, and other mechanistic details that I had never seen at the bedside. Unfortunately, the experts provided very different clinical definitions, ranging from ‘‘mild anaphylaxis’’ (simple urticaria) to a requirement for hypotensive shock. On that broad severity spectrum, most emergency physicians were in the latter camp, with a reluctance to consider the diagnosis until there was shock.
His research shows that allergists are able to diagnose anaphylaxis pretty accurately based on multiple symptoms, not all of which present themselves in every patient every time, and unsurprisingly resort to the use of injectable epinephrine more readily than emergency department docs.
This is not a theoretical exercise. We read this account a few months ago by one of our friends at the Arizona Food Allergy Alliance [AFAA]:
On December 7th, I was in anaphylactic shock at lunch time at Hospital A. They did a fantastic job treating me and were very knowledgeable. Six hours later, at home I had a secondary (biphasic) anaphylactic reaction. Since I was already on hospital-prescribed meds, I didn’t know if I could use my EpiPen so I went to the hospital near my home and was accused of being a drug addict. I mean OBVIOUSLY I was on street drugs since I was convulsing, gasping for air, couldn’t speak (VCP), and drooling on myself since my throat was closed shut and I couldn’t swallow…and I kept passing out. They ran toxic screens to “see what it was I took” and did X-rays to see “why I couldn’t breath.” My family and I kept insisting I was anaphylactic and kept pointing to my medic alert bracelet and stating I was already treated for this once earlier. The doctor refused to treat me for allergies because MY FACE WASN’T SWOLLEN – which is the ONLY symptom I NEVER get. He said, “You don’t even have a rash!!!” The nurse said, “Oh yes she does, its all over her neck, shoulders and back and spreading down her stomach like hives.” When I checked out the nurse said I should take Ativan so I don’t have these ridiculous panic attacks. Oh, yes, I filed big complaints.
It shouldn’t be this difficult. Hundreds of thousands of parents and food-allergy patients have mastered these criteria:
Any SEVERE SYMPTOMS after suspected or known ingestion: One or more of the following:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN: Many hives over body Or combination of symptoms from different body areas:
SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips)
GUT: Vomiting, diarrhea, crampy pain
Emergency departments can do it, too. All they have to do is click on Action Plans at the top of this page and then go to Food Allergy Action Plan, where these plans are available in a choice of languages, including (a la Mr. Shaw) English and….English.