Natalie Giorgi, age 13, was in the campground lodge at Camp Sacramento on her final night of camping with her family. The snacks served included a creamy covered Rice Krispie snack.
She took a bite and a family friend reported, “She immediately knew that it wasn’t right, spit it out and went to tell her mom that something had peanuts on it.” Her mother sampled the treat, as did the friend, and both confirmed it tasted of peanuts.
Natalie was monitored by her parents for 20 minutes, her father a physician, and it is reported that she showed no symptoms. Then she vomited one time and had a shortness of breath.
Her father then administered the first of three EpiPens to deliver epinephrine, the correct lifesaving medicine for an allergic emergency, and he gave her oxygen. Natalie was in anaphylactic shock, had a cardiac arrest and died.
Another beautiful young child lost to severe allergy – Anaphylaxis. What can we learn from this case? The comments are coming in that everyone did everything right; and they did it right away. We are told that “most deaths from anaphylaxis are avoidable but some are inevitable none the less.”
We believe we may have found a fatal flaw in what is being taught about first aid for anaphylaxis.
Natalie’s death illustrates the gap between criteria used to diagnose anaphylaxis at consultation in a doctor’s office versus in a real world emergency. All the guidelines, research papers and experts have set up criteria to diagnose anaphylaxis from the history of a previous event. We need some definition of anaphylaxis to be able to “make the diagnosis”. So the physicians, health care workers, family and the patient describe and discuss what were the symptoms.
However a dangerous drift has occurred in the use of those definitions: They are being applied in the field in an emergency when the instruction on how to recognize and act in a real emergency is not the same as what appears in guidelines which were created for a different purpose.
Faced with a real emergency, it is dangerous to wait for symptoms to appear until you get “enough” to make a diagnosis.
Think about it in these terms: A person who has ingested their allergen is like someone sitting on top of a barrel of nitroglycerine which can explode at any time. Get the person out of there! Don’t wait for even the first explosion; it may not give a warning and the destructive effect could be massive.
Symptoms can be rapid or delayed, symptoms in the same patient may be different from one episode to the next, so how can we use definitions and criteria that were designed to be used in a doctor’s office, hospital or research study? Definitions and criteria that are not designed, nor for that matter researched for this application, for the typical real world allergic emergency.
For the same reason, some people call reactions “mild” or “severe” anaphylaxis. Maybe, and that is a big maybe, that could be done when calmly discussing things a few weeks after the event, but what about as things are evolving before our eyes? In this situation we currently apply criteria that do not work in an allergic emergency – anaphylaxis. Nathalie did not develop anaphylactic shock 20 minutes after her eating a snack, she was in that process from the first bite.
IF THE PATIENT HAS THE POTENTIAL FOR ANAPHYLAXIS AND THERE HAS BEEN A KNOWN OR SUSPECTED EXPOSURE, THEN THE EMERGENCY PROTOCOL SHOULD BE ACTIVATED; IN OTHER WORDS GIVE EPINEPHRINE. WE DO KNOW THE EARLIER THE EPIPEN IS GIVEN, THE BETTER THE OUTCOME.
Poor Natalie and her family. She was known to be peanut allergic, she sensed that something was wrong and realized it was peanut. At that point an EpiPen could have been / should have been given and Natalie taken to hospital by ambulance. An exposure was suspected and confirmed by her mother and the family friend, it could be expected that she might be in / developing an anaphylactic reaction / shock. At that point an EpiPen could have been / should have been given and Natalie taken to hospital by ambulance. There is no downside to giving the EpiPen. Twenty minutes passed and then she showed symptoms; very unfortunately by that time it was too late.
In an allergic emergency we do not have to “make” a diagnosis, we do not have to use strict criteria, what we must do is recognize the potential for a deadly reaction.
We understand that the family including her physician father did everything exactly as is being currently taught. Unfortunately the instruction on how and what to recognize and act in a real emergency is not the same as what appears in guidelines which are intended to be used for a different purpose. That is not a gap, it is an abyss into which people are falling to their death.
Dr. Mark Greenwald MD FRCPC
Co-author of the anaphylaxis first aid course at epipentraining.com