Saturday, June 23, 2018

The Great Adrenalin Sweepstakes

drawing by Suzanne Dunaway

Allergy emergency take one: Charles was on vacation in Tuscany when he got stung by a bee, felt his throat start to close, and headed for the nearest Emergency Room. They recognized impending anaphylactic shock and knew there’s only one way to be sure it won’t be lethal: a shot of adrenalin, which starts working in seconds. The docs gave him the injection, Charles felt better, he stayed under observation the rest of the afternoon, he went home with a prescription for a few days of pills. Ordinary modern medical care.

Allergy emergency take two: Margherita knew she was horribly allergic to nuts. The scoop for her coffee and coconut gelato must have been dipped first in hazelnut or walnut flavor, because she felt her chest begin tightening up. Off to her local hospital, where things started going sideways. The head of the Emergency Room didn’t believe in adrenalin. So his staff gave her only a shot of cortisone, which doesn’t start to have an effect for hours. By the time the medication did kick in Margherita was struggling to breathe. She was lucky, and survived to tell me the tale.

In the first decades I worked here the anti-adrenalin school held sway in Italian Emergency Rooms, at least those within range of Rome. By now things have improved considerably, and most patients who need it do get that magic injection of adrenalin in the Emergency Room.

But though we’re well into the 21st century, I’d estimate that the bad old policy still holds sway at about one ER out of six – which means Russian Roulette for anyone who might be going into anaphylactic shock. One of those eternal Italian mysteries, like why secretaries always tell you to call back instead of taking a message.

Last month a patient provided a scary new twist on the allergy theme: when her throat started closing up at 3 am she rushed to an ER, walked up to the glass barrier with her head tipped backward (the only way any air could get in), and told the triage nurse she couldn’t breathe. The nurse told her to go sit in the waiting room. Three hours later she and all the 15 other supplicants hadn’t seen the shadow of a doctor. Since her throat still hadn’t closed altogether my patient figured she’d live, and went home.

Moral of the story: if you’re visiting Italy and know you have a potentially life-threatening allergy, be sure you bring along an up-to-date Epipen. Locals can obtain the equivalent free at public hospitals, but it can be very difficult to find one being sold in regular pharmacies.

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  1. Not very generous towards your host country.

    1. Giuseppina, I didn't neglect your comment on purpose last June, I simply never received it. Gmail seems to consider many comments to be spam... Anyway I'm sorry you took it that way, I'm just calling things as I've seen them: some Italian ERs use adrenaline and others, for mysterious reasons, do not. Look at the comment below from Dr. Bresciani, an Italian allergist who is even harsher than I am.

  2. Incredible stories! But why this post appeared to me only now when you mentioned it to me a couple of days ago? ☺

  3. Dear Susan,
    adrenaline prescription has been for me, as an allergist, a nightmare.
    As a MD of the Italian Public Health System I've been fighting not only to be able to have it reimbursed by the system but also desperately to have doctors in ER use it, and that is the biggest difficulty.
    It takes time to change habits and I think it will take another 25 years maybe before it is used currently when needed despite indications and guidelines.
    So, YES, don't forget to bring your Epi-pen when traveling !!!

    1. I'm glad to have confirmation from an allergist, but sad for the mad state of things...