This is a very hard article to write. Another food allergic child with asthma died this month following an episode at school: Javier Avina, age 10, who attended school in Wallaceburg, Ontario. My heart goes out to Javier for his suffering and to his friends and family. This is truly tragic, and it brings to light some very hard lessons for us all.
I first learned of Javier’s death last week, and although it was positioned as an asthma-related death, I guessed that he had food allergies. Today, this was verified for me in Allergic Living’s article. Javier was allergic to peanuts and eggs.
Javier complained to his teacher that he wasn’t feeling well. He went to the washroom to vomit and used his rescue inhaler at some point. His teacher called the office and sent Javier off to walk there alone. This is what I call the walk of death.
Sabrina Shannon took the walk of death alone at her high school in September of 2003. It’s automatic for our children to do what the teacher tells them to do and walk off alone when gravely ill, but surely our children with asthma or allergies deserve an adult to accompany and assist them and help orient the office staff, who will then be in charge of their care. Better yet, a sick child deserves to remain seated or lie down with feet elevated to keep blood in the core or on their side if vomiting, and help should come to him or her. This is Hard Lesson #1.
An autopsy has been conducted and in about three months, we will learn if Javier died from food induced anaphylaxis or from an asthma attack. Thankfully, the Coroner ordered a test that looks for antibodies produced during an asthma attack, and another test that looks for an enzyme produced during an allergic reaction (these tests are not always done). This is, however, a distinction without a difference when it comes to first aid. Whether Javier was having an asthma attack or an allergic reaction, in both situations, the emergency rescue medication is epinephrine. This is Hard Lesson #2.
There is a link between asthma and epinephrine which I’ve written about previously, and it’s part of the curriculum of my online first aid course First Aid For Anaphylaxis: An Allergic Emergency, which follows the protocols set out in the World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. Expanded labeling indicates use of an EpiPen for temporary emergency treatment of severe life-threatening asthma attacks.
That is, when a rescue inhaler isn’t providing relief or can’t be administered (for example with a patient losing coordination or consciousness), injecting the patient with an EpiPen is the treatment to provide. The CSACI adds that epinephrine can be used to treat life-threatening asthma attacks as well as anaphylactic reactions, and that asthmatics who are at risk of anaphylaxis should carry their asthma medications with their epinephrine. Javier was carrying an EpiPen on the day he died.
The coroner stated to The London Free Press that Javier did not get all the care that might have saved him, as school staff were aware that he carried epinephrine due to food allergies, and yet they did not use it. My guess is that they didn’t realize his symptoms were two of the symptoms of a food allergic reaction (vomiting and trouble breathing), that one or two symptoms alone justify use of epinephrine, or that to ensure the best chance of survival, Javier needed an EpiPen injection within five minutes from the start of the reaction. Immediately following the injection, he should have been laid on his back with feet elevated above heart level or on his side if more comfortable, and 911 called. Instead, he used his puffer again and was given an air mask.
Specifically, Javier should have been injected by his teacher in the classroom, or at least by the staff as soon as he arrived at the office, and the Coroner also stated this. As we see time and again with allergic injury and death, Javier collapsed within five to ten minutes after he arrived at the school office, and Javier’s EpiPen wasn’t administered until five minutes after he collapsed, when paramedics arrived. Had Javier survived, at best he would be severely brain injured due to lack of oxygen. This is Hard Lesson #3.
I learned today from Allergic Living’s excellent article that Javier’s asthma controller inhaler (which manages underlying inflammation in asthma) was expired, but a life threatening asthma attack can happen with unexpired medication too. Sometimes it simply isn’t enough to control the reaction, sometimes the patient can’t coordinate a proper inhalation, and that is where epinephrine comes in. Before “puffers” were invented sixty years ago, epinephrine was always the emergency rescue treatment for asthma. I wonder if there was discussion about the pros and cons of these devices when they were invented, and whether or not people would remember what medication to use when rescue inhalers don’t help.
Javier’s emergency treatment at the school was a failure, whether he suffered an allergic reaction or an asthma attack. With or without an Individual Medical Emergency Plan, you can inject epinephrine during an emergency without consequence as a Good Samaritan. It is not sufficient to call 911 and wait for help to arrive. To help avoid any confusion when asthma alone is suspected, I suggest that every Emergency Action Plan for children with asthma state that “If rescue inhaler does not provide significant relief, use EpiPen immediately, then call 911”. This is Hard Lesson #4.
To share this article, please use the icons below, or copy and paste this link: http://blog.onespotallergy.com/2016/04/tragic-death-of-javier-avina-teaches-hard-lessons-to-us-all/
For further information on this subject, please go to Epinephrine Saves Lives For Anaphylaxis AND Severe Asthma Attacks written by Dr. Paul Ehrlich for my blog: http://blog.onespotallergy.com/2012/01/epinephrine-saves-lives-for-anaphylaxis-and-severe-asthma-attacks/