Why You Need to Know More Than An ER Doc

This post was inspired by a conversation with some great people who work for an amazing allergy-related social profit organization Canada. At one point, we discussed the misconceptions and misinformation that even some medical professionals have about anaphylaxis. I've certainly been told some odd and incorrect things by people with an M.D. after their names:

1. If you administer your auto-injector, you don't need to go to the ER. FALSE! It's not magic. It just buys you time. Many people need additional medications, including more epinephrine. You are literally risking your life if you don't call an ambulance and head to the hospital.
2. Vomit the food back up and you'll be fine. VERY FALSE! If your throat is closing up, you risk choking or aspirating on your own vomit, making the situation even worse.
3. The third issue was that a paediatric doctor I know didn't know how to use an injector in practice and so injected it and let go immediately. While any amount of epinephrine is better than none, hold down that auto-injector for up to 10 seconds. The pressure also helps prevent silly amounts of bleeding.

So, that discussion led to my quick grievance about the lack of an anaphylaxis protocol in ERs. I have mentioned this before and firmly believe that anyone at risk of anaphylaxis should come up with an ER plan in conjunction with their immunologist or allergist. That plan should be communicated to friends and family in case the person is not able to communicate. Put it on paper and keep it in your allergy kit.

The reason behind this is because ER doctors have done everything from give me salbutomol and nothing else (my asthma does not act up during an anaphylactic attack) to giving me a diphenhydramine drip and then discharging me after two hours even though I was still symptomatic. The recommended minimum is four hours and there was no mention of taking diphenhydramine or watching for secondary reactions for 24-72 hours. One doctor rudely asked me what I wanted him to do while my throat was closing up and no medication had been administered by ER staff. I show no external signs of anaphylaxis; so, this may explain some of the oddities I've experienced, but there's definitely no good excuse.

Despite all of that, I do not blame ER doctors. They're unfathomably busy and have to deal with such a myriad of conditions and patients. Mistakes happen, but not because doctors are reckless or don't care. They happen because they may not have enough specific training (consider the likelihood of knowing every disease and its treatment in the world. Gregory House M.D. is fictionally crazy after all.) or because areas like ERs and ORs involve a lot of people, responsibilities, stress and various, ever-changing situations. If a doctor has a patient crashing in one room, the girl whose face isn't swollen and looks just fine will not seem like a priority, even if she should be triaged as though she is.

Specific steps need to be taken upon admittance and post-care. Doctors also need to realize that anaphylaxis does not look the same in everyone. Even the same patient can react differently at different times. Just as there are now checklists for ORs to ensure that protocols exist and are followed (developed by WHO), I would like to see protocols developed for the ER. This takes a lot of the guesswork away from already busy individuals who should be the poster adults for multi-tasking. Where there is uncertainty, there are errors. Too many people died from asthma attacks in Ontario before proper triage and treatment protocols were developed. So, let's take away the uncertainty.

I will not delve into my opinions of what that protocol should look like, because I am not a medical professional. However, should this post be read by some hospital administrator somewhere, please make a plan. If I know what it should like, your staff can draft it pretty quickly. If you have anaphylaxis or care for someone who has it, make a plan with your immunologist. I'd like to say you can trust an ER doctor with this, but it's just not a certainty.

Haddock, Chickpea & Potato Patties (My Attempt At A Recipe)

If you've read some of my posts or my FAQ section, you know that while I love working with recipes, I have never tried to document any of my kitchen experiments. While I say that it's because I'm lazy, it's not really. I love cooking and I love great recipes whether they're complex or simple (check out gojee.com), but while I'm methodical and a perfectionist about some things, making recipes just isn't one of them. I'm happy to rely on other people who do it better than I do and remain a bit of a free spirit in the kitchen.

However, this one worked out well and it's fairly simple. Plus, my teaser post on Twitter garnered a recipe request from eos_girl; so, if you like it, send your thanks her way. While it was my dinner, I think it would work splendidly as an appetizer or hors d'oeuvres. Making them a bit larger and serving with a lovely green salad or in a pita would be spectacular, too. I currently have a jar of Aki's Fine Foods Coriander Chutney in the fridge; so, I tried it with that and it was spectacular. If you're allergic to fish or just don't eat it, skip that part and add cooked quinoa and whatever spices you like. If you don't have haddock, I was initially going to do this with cod; so, I'm sure it would be lovely, too.

Anyway, here goes:

Haddock, Chickpea & Potato Patties with Coriander Chutney
Makes 14-ish

1 1/2 large haddock filets, poached, skin removed, chopped into chunks
1 can of chickpeas, drained
1 medium-sized potato, roughly chopped and boiled (skin removed after boiling)
1 1/4 cup panko
2 cloves of garlic (or more depending on your preference), smashed and roughly diced
Thumb-sized piece of ginger, skins removed, roughly diced
3-4 scallions, thinly sliced
1/4 medium red onion, roughly chopped
Canola oil for frying
1 - 1 1/2 tsps of salt (depending on your preference)
A couple of dashes of pepper (depending on your preference) 
Coriander chutney (found in Indian stores)

1. Poach the fish in water until cooked and boil the potato until soft enough to mash.
 2. Combine all ingredients, except for the canola oil, in a food processor. Give it a few turns so everything is combined. It's lovely to see bits of scallion and whole chickpeas in the finished patty; so, don't be too particular. Make sure to spoon down the sides and toss the mixture a bit to ensure everything is combined evenly, especially the salt.
3. Make patties about palm-sized and about 3/4s of an inch thick. I ended up with about 14.
4. Preheat pan on medium-high heat with a few good glugs of canola oil. The patties shouldn't be swimming since you don't want to deep-fry them, but there should be a decent coating of oil on the pan.
5. Cook 3-4 minutes on each side. You'll have to watch it very carefully at this point to ensure it doesn't burn and that you're cooking it all the way through. The sign that one side is done is a just visible pillar of white smoke coming from the pan, but way before you smell anything burning. A good sign that a side is done is that it should be a deep, crispy brown.
6. Place on paper towels to absorb some of the extra oil.
7. Continue to add oil as needed and fry remaining patties.
8. Serve warm with a coriander chutney. If you can't find it premade or just prefer to make your own, there are a lot of recipes on the internet and it's quite easy to make. Its claim to fame is as a partner to samosas. Yum.

That's it! My first recipe and proof that I should never make recipes. Feel free to play with this one especially if it's not looking right. This was just a result of having some haddock that needed to be used and I'd already been thinking about making a chickpea/edamame patty but didn't have all the ingredients I needed. I'm pretty happy I was out of limes!

One note, I didn't add any hot spices because I was keeping it simple. Coriander chutney can be spicy; so, if you're going to eat the patties with the chutney, best to either not add any chilies or to just add a bit.

If you cook this, let me know how it goes!

Atopy and Ocular Conditions

Why Your Optometrist Should Know You're Atopic

Before I continue, I would like stress that nothing you read here should cause you to stop using your medications as prescribed. I am not a medical professional and I am not providing medical advice. These are things you must discuss with your doctor. The only thing that should change is that you should make an effort to get regular ocular screenings (i.e.: See your optometrist!).


It's not something my dermatologists or immunologists have ever discussed with me. Until I started working in an ophthalmic practice, I had no idea that there was a link between atopy and certain eye conditions. My optometrists certainly never asked if I had eczema or asthma. It turns out the two seemingly disparate fields are connected.

People with atopic conditions may be at risk of developing cataracts and glaucoma due to the use of steroids. However, the actual risk is difficult to quantify. The data and evidence isn't there yet. According to the University of Maryland Medical Center, the risk of developing cataracts is well-known with oral steroids, but less clear and sometimes contradictory regarding inhaled and nasal-spray corticosteroids.

The American Academy of Allergy, Asthma and Immunology answered this question as recently as March 2012. However, even their response was tempered. The data does not exist to support a clear answer either way. One of the recommendations included in the abstracts contained in the article is that steroid nasal sprays should remain prescription medications to ensure monitoring by a medical professional.1

I recently started using a new nasal spray for my allergic rhinitis. Since, I always read the instructions, I couldn't help but miss the note about talking to your doctor if you have glaucoma or making sure to have regular eye exams to screen for glaucoma. While this may seem precautionary since there is no clear data, it's a reasonable precaution. Glaucoma screening is an easy enough thing to have done.

Regarding the risk of topical steroids, once again, the data is not clear. However, the general recommendations seem to be that the use of steroid creams should be limited around the eye in case a link to glaucoma exists.2 Eyelids are made up of a thin layer of skin, allowing the steroid to be more easily transmitted to the eye which is why this area is of more concern than others.

Lastly, according to CNNHealth.com, for those who have severe eczema around the eyes, complications such as blepharitis and conjunctivitis can occur. These are conditions which can also affect the quality of your vision.

The important thing is to be aware of these conditions and have open discussions with your all of your doctors about ways you can reduce your risks and the potential of developing these eye conditions in order to develop a screening plan. Once again, do not discontinue the use of any of your medications. Risks in medicine are not an absolute as I've discussed before and these conditions need many, many years of exposure before potential manifestation. With proper screening and early diagnosis, these conditions can be managed with often excellent results.

Footnotes

1. Bielory L, Blaiss M, Lieberman P, et al. "Concerns about intranasal corticosteroids for over-the-counter use: position statement of the Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology." Ann Allergy Asthma Immunol. 2006 Apr;96(4):514-25. as included in "Risk of development of cataracts and/or glaucoma from inhaled steroids", American Academy of Allergy Asthma & Immunology
2. Garrott HM, Walland MJ. "Glaucoma from topical corticosteroids to the eyelids." Clin Experiment Ophthalmol. 2004 Apr;32(2):224-6.

Links

Atopic dermatitis - Treatments and drugs (Mayo Clinic.com)
How to treat eczema around the eyes (Livestrong.com)
Atopic Dermatitis: Possible Complications (EczemaNet - American Academy of Dermatology)
Atopic dermatitis (eczema) (CNNHealth.com)
What Causes Cataracts (University of Maryland Medical Centre)
Risk of development of cataracts and/or glaucoma from inhaled corticosteroids  (American Academy of Allergy Asthma and Immunology)
Side effects of asthma medicines  (Asthma UK)
Eye Allergies (American College of Allergy, Asthma & Immunology)

Allergies, Atopy and Health Care Reform: Why You Should Care

I've written about why public relations matters for atopic and allergic people. This post will deal with why allergic and atopic people need to get involved with government relations, specifically health care policy. While this post is about the future of health care policy in Canada, I think some of the core messages certainly apply elsewhere. That said, Canada clearly has a lot to learn from many other Western nations who handle health care a lot better than we do.

A few weeks ago, I attended a political convention in Toronto. I will "out" myself as a member of the Liberal party at this point. Now that it's out there, you can put whatever spin you wish to on anything I write here, but I am writing this with my unbiased hat on. Liberals have certainly not done anything to advance health care recently and are not in a position to do so at present.

At the Liberal Convention, I had a great opportunity to hear talks by the Honourable Dr. Hedy Fry, M.P. for Vancouver Centre and Liberal Health Critic, and Senator Art Eggleton from Toronto and Deputy Chair of the Committee of Social Affairs, Science and Technology. The latter committee just released an extensive report on the 2004 Health Accord which expires in 2014 - "Time for Transformative Change: A Review of the 2004 Health Accord". If you're not familiar with the jurisdiction involved, very basically health care is administered by provinces, but the money is transferred from the federal government to each province. Some of the exceptions are health care for Inuit, First Nations and Aboriginal peoples as well as veterans and military personnel. Health care for those groups are administered and funded by the federal government.

Recently, I also attended a talk by Globe and Mail columnist and reporter, André Picard entitled "The Path to Health Care Reform: Policy and Politics" organized by the Conference Board of Canada. This was another amazing talk about the future of health care in Canada.

Both Fry and Picard pointed out that the current system of Medicare was created in a different time (the 1950s) and designed to fulfil a much different purpose than it does currently. Medicare was for acute cases and hospitals were for "birth, surgery and death" according to Picard.
  
The medical system is much broader now. There are numerous chronic conditions like asthma, eczema and allergies that require life-long monitoring, treatment and medications. However, the system we currently have was never meant to deal with these kinds of issues. On the most basic level, diagnosis and treatment is still very fragmented. I currently see an immunologist and family doctor. In the past I have seen a dermatologist, pulmonologist and psychiatrist. In the future, chances are good that I will need an ophthalmologist. All of these conditions are related to atopic and allergic conditions, but they're all dealt with in a vacuum. This isn't the same in all countries. In other countries, there are hospital departments which deal with most of these conditions in a much more holistic way, but I have never experienced the same thing in Canada. What makes it even more difficult for people with multiple chronic conditions is the lack of e-records, something discussed by both Fry and Picard. I keep a spreadsheet with the basics of my medical information (treatments, medications, etc.) and print it out when needed, but this needs to be done on a national scale so it can be easily accessed by all relevant doctors and contain thorough data.

What really struck me about Picard's talk is that he addressed the ideological barriers that exist in Canada surrounding Medicare. To critique health care is to risk a politician's career because the concept of universal health care is so entrenched in Canadian pride and identity. We think it distinguishes us, makes us better than everyone else, when really there are a lot of countries who administer universal health care better than we do. Picard called our view of health care "myth"-based, when it should be fact-based. It should be a rational discussion of how to improve a half-century old institution.

I won't go much further into his discussion, because I think it's worth hearing from him. I will include the Globe and Mail article and the video and audio to his actual talk below.

Regarding Dr. Fry's talk, she outlined four areas that need to be addressed:

1. Pharmaceutical strategy

2. Health Human resources

3. E-health

4. Delivery of care

Every point in there is important for those of us with atopic and allergic conditions. The amount of medications I use in a year adds up to a staggering financial amount. I feel I am an otherwise healthy person, but the fact is that I need medications to maintain my health. An important part of Medicare should be financial assistance for medications, yet it's not something we have unless one is hospitalized or meets very narrow criteria.

There is also a shortage of certain specialists and too many dermatologists and family physicians who spend more time selling cosmetic procedures instead of dealing with their medical patients in a timely fashion. Something in there has to change. There should be no reason to wait six to eight months for an appointment. There are immunologists and dermatologists who have figured out the perfect balance and that needs to be looked at.

E-health is a simple concept, but is proving difficult to implement for many reasons, some valid and some not. However, for people who will deal with lifelong conditions, it's necessary. Canada is also the second largest country in the world in terms of land. It is not feasible for every population in Canada to have access to each kind of specialist it needs; however, telehealth (something being done very well by organizations like the Ontario Telemedicine Network) is cost-efficient and practical. Technology and services like this need to be rolled out across the country so that every remote community has access to the best care possible.

Delivery of care deals with multidisciplinary, holistic teams and more of a focus on home care. This is something that is pretty difficult to disagree with. However, it's not happening on the scale it needs to. Considering the fact that seniors form a larger proportion of Canadians than ever before, it's past time to act.

So, what does all of this mean? It means that the health care system we are all proud of needs fundamental restructuring. It means that as people with chronic conditions or as the parents of those with chronic conditions, we need to start pushing our M.P.s and provincial representatives to change now. Health care is something that deserves and requires federal leadership and whatever your political leanings, that's the exact opposite of what the current government wants.

I am always amazed at the amount of backlash when some meaningless person out there makes a disparaging or intolerant remark about kids with peanut allergies. Clearly we have power, but we don't always use it in the most productive way. Regular, motivated parents are responsible for ground-breaking legislation like Sabrina's Law. This is the next step to that kind of legislation. It's about making sure plans are in place to help people with atopic and allergic conditions throughout the rest of their lives.

At some point, your allergic child with asthma or eczema is going to be my age. They're going to be dealing with the health care system all by themselves and wouldn't it be amazing if they didn't have to spend a lot of their income on medications just so they could live a regular life? Wouldn't it be amazing if they didn't spend hours of their time on visits to doctors? Wouldn't you feel better if they had an anaphylactic or asthmatic reaction and the hospital had access to all of their medications and medical history? Shouldn't it be a Canadian right to live in any province and have access to the same level and type of health care services?

That's what this is all about. So, let's get this started. 

Links You Should Read: 

The Path to Health Care Reform: Policy and Politics (VIDEO)- André Picard (CPAC) 

The Path to Health Care Reform: Policy and Politics (AUDIO)- André Picard (Conference Board of Canada) 
Dragging medicare into the 21st century - André Picard (Globe and Mail) 
Time for Transformative Change in Health Care - Senate Report (Committee of Social Affairs, Science and Technology) 
Federal-provincial health accord expires in 2014, experts say it's time feds talk about their plans - Bea Vongdouangchanh (The Hill Times Online)

Links to Get Started:

Government of Canada - Members of Parliament

Alberta - Members of the Legislative Assembly

British Columbia -  Members of the Legislative Assembly

Manitoba - Members of the Legislative Assembly

Newfoundland and Labrador -  Members of the House of Assembly

New Brunswick - Members of the Legislative Assembly

Northwest Territories - Members of the Legislative Assembly

Nova Scotia - Members of the Legislative Assembly

Nunavut - Members of the Legislative Assembly

Ontario - Members of Provincial Parliament

Prince Edward Island -Members of the Legislative Assembly

Quebec - Members of the National Assembly

Saskatchewan - Members of the National Assembly

Yukon - Members of the National Assembly

Lessons to Learn from Anaphylaxis Deaths

Every time I hear about another death from food allergies, I am horrified, sad and take it as another reminder to be vigilant. I just read an article about Diallo Robbins-Brinson who passed away in Atlanta this past Monday. My intent here is not to be critical. My intent is to point out what must be learned from this.

Allergies are not a fixed thing. Personally, my food allergies developed over almost a decade and within that time, some came and went a few times. Even now, in my 30s, I have some that may have disappeared and I'm careful to eat a variety of foods and never become dependant on one thing should I develop another allergy. I also know a handful of people who developed allergies in their 20s and they had no history of allergies, personal or familial. If you are allergic to anything, you unfortunately must assume that you can develop other allergies.

The other point is that in the article, it stated that according to his mother, Robbins-Brinson was "so accustomed to avoiding peanuts, Diallo no longer carried an Epi-Pen". It's pretty obvious why this horrifies me. Sorry to use that word twice, but that's what it is - horror. I am very accustomed to avoiding eggs, dairy, certain nuts and shellfish, but under no circumstances would I not carry two EpiPens with me. If I didn't have my EpiPen (I always have my EpiPen), I wouldn't eat.

Complacency and comfort are things allergic people can never afford to be. Not ever. We can never get accustomed to being safe. We're just not. We can live our lives normally and be positive and optimistic (and we should be), but no matter what, we have to be critical and be prepared for the worst.

Once again, I am not criticizing the family at all. This was an undiagnosed allergy and I can certainly understand why Robbins-Brinson did everything the way he did. I've written before about how I can feel "too safe" when I'm staying with friends and family.

What I am saying is that parents and caregivers should have frank discussions with their child's/teen's immunologist and their child/teen. For adults, being older doesn't mean you're wiser and it certainly doesn't mean you can stop an anaphylactic attack. If any doctors are reading this, you need to be a lot more frank with your patients. A little bit of fear is not a bad thing if it makes someone carry an EpiPen or wear a MedicAlert bracelet. I'll admit that a horror story about a freshman who was force-fed eggs during university initiation and suffered severe anaphylaxis was what it took for me to become so vigilant about my own health years ago.

I would love to see an awareness campaign about always carrying epinephrine auto-injectors developed by a social profit allergy organization and funded by the makers of epinephrine auto-injectors. It worked for seatbealts.

So, please learn the lessons here. Allergies change and under no circumstances should anyone with allergies or asthma be without an epinephrine auto-injector or medical bracelet. It's just not worth it.

Celebrating Food Allergy Awareness Month in Canada

It's that time of year again. This is a great chance to educate others about what it means to be food allergic while getting involved with some great Canadian organizations and making a difference. There are so many simple ways to show your support.

Say Thanks
1. Anaphylaxis Canada wants you to nominate a "Difference Maker" - someone in your life who has made a difference in keeping you or someone you love with allergies safe. For information and deadlines, please visit: http://www.anaphylaxis.ca/en/media/hot_topics.html?news_id=17
2. OlliLolli is currently looking for an Allergy Aware Hero. Nominate someone who makes an outstanding difference to promote allergy awareness in Canada. To nominate someone and check out the rules, please visit: http://www.ollilolli.com/blog/the-2012-olli-lolli-allergy-aware-hero-award/

Volunteer
There are plenty of social profit (a.k.a. not-for-profit) organizations in Canada that need your help. To find out more visit great organizations like Anaphylaxis Canada, The Eczema Society of Canada, The Asthma Society of Canada and the Allergy/Asthma Information Association. No matter how much time you have to spare, you can find something to fit your schedule and make a difference.

Fundraise
All across the country, allergy walks are happening throughout May. Get involved and fundraise for a worthwhile cause. For more information on EpiPen Take Action walks occurring throughout the country, please visit the Allergy/Asthma Information Association website.

Learn
Anaphylaxis Canada has a series of information sessions in Barrie, Toronto and Hamilton. For dates and to register, visit the event page at: http://www.anaphylaxis.ca/en/media/events.html?news_id=11

For even more, visit Anaphylaxis Canada's Hot Topics page. There's great information about how to order posters, get involved with the WhyRiskIt teen program and even learn about the Sabrina Shannon Memorial Award.

Have some more ideas or want to share what you're doing? Please feel free to share in the comments section!

Happy Allergy Awareness Month!

10 Great Things About Being Allergic & Atopic

There really are some benefits to having allergies and atopy. In honour of World Allergy Week, I've decided to compile my top ten list. Of course, this list is a bit tongue-in-cheek, and definitely not intended to make light of any of these conditions, but all of it is based on my personal experiences.

1. Because you're allergic to so many things, it's pretty impossible to gain too much weight.

2. When you're faced with a really nasty looking, oddly orange-coloured casserole made with cream of mushroom soup, orange juice, overcooked salmon and topped with Ritz crackers, you can truthfully say you're allergic and lie that you're sad you can't eat it since it looks wonderful.

3. The chefs at restaurants frequently make your custom, allergy-free meal way better than your dinner companions' meals and you are envied.

4. Since every restaurant isn't allergy-friendly you get to pick where you want to go when you eat out with friends and family (though you never take advantage of course).

5. If you have an allergic or asthmatic reaction and the ambulance isn't close enough, you get a whole team of firefighters in uniform instead.
 
6. You know enough medical terms that you can actually follow what the actors are saying on House.

7. You baby your skin so much that you'll look 30 when you're 45.

8. To avoid eating scary casseroles (see number 2), you start cooking and realize you're really good at it.

9. You are always well-stocked with epinephrine, anti-histamines, Kleenex, lotion, lip balm, etc.; so, you are literally and figuratively a life-saver at any event.

10.  You know what you can't eat or use; so, you love trying out safe, new foods and products. Your friends and family love your recommendations.

If you've got anything to add, I'd love to read it; so, please add it to the comments below!