Monday, September 15, 2008
Friday, January 11, 2008
While this may not apply directly to emergency management personnel, it does concern us as citizens, parents, and family members. Anaphylaxis (life-threatening allergic reactions) affects more and more people each year.
The following article, from the Journal of Emergency Medical Services, describes a fatal allergic reaction, and demonstrates one reason why first responders are being trained to assist with epi-pen administration.
It is probably safe to assume that the coworker driving the man to the hospital was going at least 40-50 mph. The worker went into cardiac arrest before they reached the hospital, which was five miles away. This implies cardiac arrest occurred within just a couple of minutes.
Obviously, the article is aimed primarily at EMTs and paramedics, so there is some terminology that may be unfamiliar; I’ve included definitions in brackets. On the other hand, we should be able to grasp the overall situation and results, even if some of the treatment details are confusing.
Some points to consider:
- Between 1 and 16% of the U.S. population is considered to be "at risk" for developing anaphylaxis.
- The overall fatality rate in anaphylactic shock is estimated to be 70%.
- Bee stings account for the vast majority of deaths due to anaphylactic shock. Reported death rates are about 50 per year in the U.S.
- The patient may require supplemental oxygen and/or defibrillation, in addition to the epi-pen.
- If you know people or encounter patients with this background, emphasize the importance of seeing their primary physician or an allergist for further evaluation. Advise these individuals of the risk of death or significant complications resulting from a severe allergic reaction. Tell these people that they may benefit from an epinephrine auto-injector, which they should have with them at all times.
The following is excerpted from the article. Any comments that I have added are in brackets and italicized.
Convenience Store Crisis
David Ross, DO, FACEP
A 29-year-old old man was working with others at a construction site. The workers encountered a beehive, and the man was stung several times by a large number of swarming bees. Immediately after this, he commented to co-workers that, in addition to the pain of the stings, he just wasn't feeling well. He complained of lightheadedness, weakness and nausea.
The others elected to load the man into a truck and drive five miles to the nearest hospital. The man began to feel worse. He complained of increased weakness and nausea as well as some difficulty breathing. The driver of the truck decided to stop at a local convenience store to contact 9-1-1 and await the arrival of an ambulance.
As the workers pulled in to the parking lot, the man became unresponsive. As one co-worker called for help, the others recognized the injured man wasn't breathing and didn't seem to have a pulse. They considered pulling him out of the vehicle to perform CPR, but left him inside because a severe thunder and lightning storm had developed, making outside working conditions hazardous.
The patient was found still in the vehicle by arriving EMS crews. He was pulseless and apneic [not breathing]. Crews quickly removed him -- in the very heavy rain -- and placed him in an ambulance. CPR was initiated. The cardiac rhythm was asystole. Epinephrine and atropine was administered, and the patient was successfully intubated. Ventricular fibrillation was noted, but the patient didn't respond to defibrillation…. Asystole recurred and CPR continued, and the patient was transported to the hospital.
En route, the EMS crew noted the patient had no obvious physical abnormalities. He had no rash and no evidence of any facial or airway swelling. Additionally, there was no sign of the multiple bee stings reported by the co-workers. In short, there was no apparent explanation for this seemingly healthy man to suffer a sudden cardiac arrest.
Upon arrival to the emergency department (ED), CPR continued. [. . .] However, he didn't demonstrate any neurologic response.
No additional history was available to the hospital staff at this point. The patient was admitted to the Intensive Care Unit (ICU).
After three days in the ICU with no improvement in the patient’s neurologic status, life support was discontinued. Limited organ donation took place. During this period, family members were able to provide missing historical facts about the patient. The man had, in fact, been very healthy except for significant reactions to bee stings. He had been encouraged to seek medical attention regarding these reactions and to perhaps obtain an epinephrine auto-injector. He had failed to do this.
The conclusion was that this patient died of anaphylactic shock. Factors supporting this cause of death included the family's history coupled with the story of the multiple bee stings at the scene and the patient's very sudden deterioration. Airway changes consistent with anaphylactic shock were identified on post mortem examination.
Anaphylaxis is caused by activation of the immune system by antigens that trigger inflammatory processes in the body. It's an extreme manifestation of an allergic process. Between 1 and 16% of the U.S. population is considered to be "at risk" for developing anaphylaxis. The most severe form of anaphylaxis, anaphylactic shock is a rare but critical emergency in which prompt recognition and treatment by EMS and ED staff is potentially life saving. [Prompt and correct reactions by first responders are equally critical]
Typical potential antigens or triggers for anaphylaxis include such foods as shellfish and nuts -- particularly peanuts. Other common triggers include antibiotics -- most frequently penicillin-based drugs.
Venom from the stings of Hymenoptera -- yellow jackets, honeybees, wasps and hornets -- accounts for the vast majority of deaths due to anaphylactic shock. Reported death rates are about 50 per year in the U.S. Allergic sensitization to Hymenoptera venom is believed to occur in about 0.4-4% of the American population. Additionally, fire ant stings have also caused anaphylactic shock.
In response to an antigen, an initial process called sensitization begins. [ . . ] Sensitization sets up a later, more severe reaction (anaphylaxis) if the same antigen is reintroduced to the body at a later date.
Symptoms and signs that may be seen with severe allergic reactions and early anaphylaxis include urticaria (itchy rash or wheals), nasal congestion, laryngeal edema [swelling of the throat], cardiac dysrythmias, abdominal cramping and vomiting. Eventually, vasodilation [enlargement or widening of blood vessels] and fluid loss can result in hypotension [low blood pressure] leading to complaints of lightheadedness and syncope [fainting].
The overall fatality rate in anaphylactic shock is estimated to be 70%. Death typically occurs from hypoxia [insufficient oxygen in the blood] and hypercarbia [too much carbon dioxide in the blood] associated with airway obstruction. Patients suffering cardiopulmonary arrest almost always die.
Treatment of Anaphylaxis
Treatment involves basic airway maneuvers to facilitate oxygenation and ventilation [. . .] Once anaphylactic shock is suspected, the primary therapy after addressing the airway is fluid resuscitation followed closely by epinephrine …. [Bear in mind, as first responders, we can assist in only a single dose of epinephrine from an auto-injector]
One concern of the use of epinephrine is excessive oxygen demand by the increased cardiac workload [. . .] [Supplemental oxygen and the use of an AED may be required]
What Can [We] Learn from This Case?
- Allergic reaction and anaphylaxis is a relatively common occurrence for EMS crews and other health-care providers. In most cases, it's easily treated with excellent results.
- On the other hand, anaphylactic shock is a rare, extreme presentation of anaphylaxis with a mortality of up to 70%. Expected symptoms and signs of allergic reactions often aren't present – possibly making the diagnosis more difficult. This combination of very rare presentation along with the paucity of expected physical findings may delay delivery of one of the primary therapies -- epinephrine. A history of recent Hymenoptera or fire ant sting should immediately suggest risk for anaphylactic shock. Food ingestion of shellfish or nuts should raise the question as well. Early suspicion and recognition of anaphylactic shock is paramount for all medical providers dealing with emergent patients.
- Epinephrine auto-injectors are extremely important to patients with known prior reactions to potential antigens or triggers for anaphylactic shock. [First responders] should be thoroughly familiar with the use of auto-injectors […] if available at the scene.
- Patient education is fundamental in reducing unnecessary deaths due to anaphylactic shock. [. . .] If you know people or encounter patients with this background, emphasize the importance of seeing their primary physician or an allergist for further evaluation. Advise these individuals of the risk of death or significant complications resulting from a severe allergic reaction. Tell these people that they may benefit from an epinephrine auto-injector, which they should have with them at all times.
In the case above, the patient was aware he had a significant allergy to bee sting venom. His family encouraged him to see a physician about this problem. He never appreciated the importance of his family's urging.
Friday, January 4, 2008
I was depressed last night so I rang a suicide hotline.
I was transferred to an out-sourced call center in Pakistan.
I told them I was suicidal...
They got all excited and asked if I could drive a truck.
I hope no one is offended. And if you are, well, then chill out, take a deep breath, and relax.
Friday, December 28, 2007
- WHO is responsible for the killing? I've seen reports that al-Qaeda was claiming credit, but other sources point at Musharraf.
- WHAT will happen next? Musharraf had just recently restored "constitutional" government to Pakistan, after suspending the constitution -- and most civil rights -- in an attempt to hold onto power. Not surprisingly, Pakistan is currently being wracked by rioting, but what is further down the road? Will Musharraf reinstate martial law? Will Bush be forced to move troops into Pakistan to maintain some semblance of order? And if so, where will he find those troops?
- WHAT exactly happened, anyway? Initial reports indicate Bhutto was shot, prior to the bomber detonating himself (what used to be called a "not-so-smart bomb"); there have been conflicting reports as to whether a handgun or long gun was used. In addition, the early report I swa from the hospital indicated trauma as the cause of death, with no mention of bullet wounds.
One thing that should go without saying is that Bhutto has been martyred for her cause. It is likely that she will exercise more power and more influence dead than she could have alive.
One other thing: Bhutto's assassination will make an already-muddled situation in that part of the world much. much worse.
Friday, December 21, 2007
Thursday, December 20, 2007
Needless to say, there was quite a bit of snark (Internet slang for sarcastic, cynical humor) about the fire. One blog, Dependable Renegade, ran a picture of Cheney talking to fire officials, with the caption, "All I'm saying is that if you're gonna set a fire, it's probably a good idea NOT to leave the gas can marked "VP" outside the door."
Friday, December 14, 2007
As a former police officer, I tend to agree with those who describe this as a hate crime (the Boston Herald article cited by FireRescue says the attackers were yelling, "Gringo, go home," which makes no sense as the attack occurred in Boston, not Cancun).
Some of the comments I have seen have been disgusting, especially to someone who has spent over thirty years in emergency services.
People like us don't go into emergency services to help only whites, or only blacks, or only Asians. We go into emergency services to help people, regardless of race, creed, or color.
It's terrifying to see my professional peers screaming about bringing back nooses, and ranting about "nigs" and "spics." Don't these people realize that we are all immigrants? Our brothers and sisters in the Boston emergency services cross all races. Of course, the Boston civil service ranks lean heavily towards the Irish, yet we don't see similar comments about "drunken micks."
Unfortunately, such hateful spewings seem to be more and more prevalent today. It's due, in part, to a natural reaction to the 9-11 terror attacks, but our society appears to be sinking deeper and deeper into a morass of hatred, distrust and bigotry.
We, as emergency services and emergency management professionals, must not allow such putrid thoughts to clog our minds and color our actions. We must maintain our professionalism.