A nut allergy nightmare at 35,000 feet [PODCAST]

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“People developing anaphylaxis will not always have five extra minutes to spare. I do appreciate that auto-injectors are expensive, but it is not at all expensive to have an ampule or vial of epinephrine on board, which can be drawn up in five seconds. Those also come in a much friendlier concentration of 1 mg/1 mL.

The chances of using epinephrine to treat a cardiac arrest patient are astronomically small compared to the chances of needing it to arrest an anaphylactic reaction, particularly if they continue to serve food containing nut products.

Parents in the nut allergy community have advocated for these changes for years. And while the airlines have taken the important step of no longer serving packets of nuts on board, little else has been done to make air travel safer for the food-allergy community. I call upon the major airlines to revise their medical kits and to offer allergy-safe meals for those in need. It is such a simple measure, and you can quite literally save a life.”

Samara Friedman is a pediatric orthopedic surgeon.

She shares her story and discusses her KevinMD article, “A nut allergy nightmare at 35,000 feet.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today we welcome back on the show Samara Friedman. She’s a pediatric orthopedic surgeon. She’s going to share her story in her KevinMD article titled “A nut allergy nightmare at 35,000 feet.” Samara, welcome back to the show.

Samara Friedman: Thank you for having me.

Kevin Pho: So we’ll get into your story and article in a little bit, but for those of you who get a chance to listen to our first episode together, just briefly share your story and journey to where you are today.

Samara Friedman: So I’m a pediatric orthopedic surgeon. I knew from a very young age that I wanted to become a physician, and pretty young also, prior to college, I decided on orthopedic surgery, and I pretty much pursued that straight through. Now I’m practicing in a private practice in northern New Jersey.

Kevin Pho: Wonderful. And you had this really, really detailed and vivid story that you shared in this KevinMD article. For those of you who get a chance to read it and experience it through your words, just tell my audience about that.

Samara Friedman: So basically, I was on an airplane and got that call that most of us get at some point in our career: “Is there a doctor on board?” And I usually do, even as an orthopedist, where my medical knowledge might not be quite as up to date as a more general practitioner’s or an emergency room doctor’s. I do try to volunteer, because you never know who else might be available. I also like to set a good example for my children, and I always try to volunteer when they do make that call for a doctor on board, which has happened twice so far to me with travel.

So I volunteered to respond to whatever medical emergency this was. They took down my seat number. They said, “We’ll let you know if we need you.” And then, once I thought everything was well taken care of, they showed up back at my seat asking for me to potentially assist. What I found out was that this was a college student who had eaten the food on the airplane and realized after doing so that there were nuts within the food, and that she had nut allergies. She also couldn’t find her EpiPens, which may have been left with her parents, who were on a separate flight. And she was having a reaction, and she wasn’t sure if it was serious or not, if it was anaphylaxis.

But a nurse initially also responded. They asked the nurse for their expertise because they didn’t want to bother a doctor if they didn’t need to, and that nurse gave her some Benadryl. When she didn’t respond, the nurse said, “Maybe it’s a panic attack. Why don’t you sit down, relax, and see how things go?”

Kevin Pho: Now, what kind of symptoms did this person experience? What was she experiencing that caused them to be of concern?

Samara Friedman: So she was having a somewhat copiously running nose. She felt like her heart was beating quickly. She felt anxious, which is a common symptom in anaphylaxis also. At that point, she didn’t have hives, and she wasn’t wheezing, but she did have some irritation in her stomach: a little nausea, runny nose, anxious, heart racing. And she wasn’t sure, again, if this was an anaphylactic reaction, a reaction to the nuts, or if she was just panicked.

Kevin Pho: And about how old was she?

Samara Friedman: She was 20.

Kevin Pho: 20. OK, so the nurse had given her some Benadryl, and then the flight staff called you up to see her. Now you’re there. What happened next?

Samara Friedman: Right. Also, I should mention her throat felt itchy as well. So I kind of took her history. She hadn’t had anaphylaxis previously. She was always able to eat things that had been made in a facility with nuts, but she just never ate something with nuts in it, more than just a cross-contaminant. And she was really concerned about, again, the itchy throat. Her nose was running, and her pulse was a little bit fast, but she was stable. She was able to converse with me without difficulty.

After some deliberation, I decided, you know, if this is anaphylaxis and it’s not properly treated, not expeditiously treated, the ramifications could be disastrous. She could decompensate and end up in a situation where maybe epinephrine wouldn’t be effective at that point anymore. If it was just a panic attack, then unfortunately she received a painful shot of epinephrine that she didn’t need, but the side effects would be minor. So given the limited medical resources on an airplane, I decided the right call was unquestionably to give the epinephrine and see how she responds, because if you don’t, it could be disastrous.

Kevin Pho: Now, the epinephrine, was that part of the flight kit, or was it just from another passenger on the plane?

Samara Friedman: So I had epinephrine with me in an auto-injector because, as you know from the article, my son is anaphylactic to tree nuts, and I always carry a number of EpiPens on me, this form being an Auvi-Q pen. I was willing to use it if need be, if the flight didn’t have their own supply of epinephrine. But I also didn’t want to use it if I didn’t have to use it, because he might need it, and he might need multiple doses. He has had anaphylaxis in the past, he does react to cross-contamination, and we were on our way to a country that uses a lot of nuts in their cooking.

So I had EpiPens if I needed them, but there was a flight kit. We went through the flight kit. The flight kit did have epinephrine, but not in an auto-injector and not in the right concentration for anaphylaxis.

Kevin Pho: So in general, what else is in a typical flight kit, or was it the flight kit on that flight that you were on?

Samara Friedman: So they had sort of a trifold packet of a dizzying array of medications, and I can’t say I recall exactly what other things were there, because I was just looking down the list to find epinephrine. They had a list in very small print, and being in my mid-40s at this point in time, it’s getting a little harder to read that small print very quickly. I saw that there was epinephrine in the packaging, and then we went through this trifold trying to find it pretty quickly.

It turned out that they only had it in a concentration that was meant for cardiac arrest, and I had to convert this into both a concentration and a form that I can inject for anaphylaxis, because it was contained within a Bristojet device, which I was completely unfamiliar with, and it’s not a device that you can just do a subQ or IM injection with. So I had to MacGyver this epinephrine from this Bristojet device and figure out how to get it into a separate needle and syringe that I could give for an IM or subQ injection, and also translate the concentration into the correct dosage for this young lady.

Kevin Pho: That seems like a pretty cumbersome process for what is not an uncommon event. As far as you know, are EpiPens generally not included in flight kits?

Samara Friedman: EpiPens are expensive. Now, the airlines may have a deal with a pharmaceutical company, if they’re buying them in bulk, that they get them a little less expensive than we do. But we’ve paid up to $600 for a two-pack of epinephrine when it was at its worst, when there were no competitors, no Auvi-Q. Now it’s still expensive, but it can cost me a few hundred dollars, and that’s a big cost for an airline for a medication that theoretically expires in a year, which is what it at least says on the Auvi-Q injector and the epinephrine injector. So I’m sure the airline could afford it. They probably prefer not to, and they just push that off to you, the doctors that have to deal with it when the issue arises.

They could easily, though, just have an ampule of epinephrine or a vial of epinephrine in the right dosage to use for anaphylaxis. I think a good number of physicians would know how to just draw epinephrine from a vial and inject it, but they might not know the right dosage for anaphylaxis. If I didn’t have a child who’s anaphylactic, as an orthopedic surgeon, I don’t think I would have known the proper dosage for anaphylaxis. I use maybe three or four medications in total in my practice. I write for Ancef, and I write for a few pain meds. That is all I do as an orthopedic surgeon in terms of medication prescribing. So to know the dosage of anaphylactic medications offhand would be pretty unusual for a typical orthopedic surgeon who doesn’t have a personal reason for knowing that.

So I do think it’s worthwhile to have the auto-injectors on the flight. A flight attendant could use it, a paramedic could use it, and a nurse could use it. So I think it’s important to push forward and have that included on flights. It’s one of the top 20 causes of a medical problem in the air, as I recently found out after doing this article and receiving a lot of feedback and additional information from people.

Kevin Pho: So tell us what happened next in your story.

Samara Friedman: So I did figure out how to give her the correct dosage. I injected it, but the volume was about 10 times the volume of an auto-injector, because the concentration was 10 times more dilute. So instead of 0.3 mL injected into her leg, it was 3 mL, very painful for her. But thankfully she responded, and within minutes of giving her that epinephrine, the itchy throat resolved, the runny nose resolved, her pulse returned to normal, and she just felt less anxious, less of that sense of impending doom that you often feel with anaphylaxis.

Kevin Pho: And then after that, did you observe her? How much longer in the flight was there?

Samara Friedman: So there were about five hours left in the flight. I observed her for about one hour. She felt fine. The flight attendants were very helpful. They said they would observe her themselves and let me know immediately if anything changed, and they suggested I take a break and get a little bit of rest on this flight.

Kevin Pho: Now, is it common for flights to have nuts in their meals on a plane?

Samara Friedman: Unfortunately, it’s more common than you would think. Most of the time, there are things made in a facility with nuts, which some people with nut allergies can tolerate and others cannot. My son is one of those who cannot. But to have it in as part of the meal, I found particularly surprising and disturbing, because this is such a common problem. In a flight of 300 or 400 people, you’re going to have at least three or four, if not more, people who can’t eat this food. And if they’re not vigilant, and most of the time we are, but we’re human and mistakes happen, you’re going to have people who are going to have a medical emergency on the flight.

And flight diversions, if they had to divert, cost the airlines a good five-figure amount, if not even six-figure, depending on the situation of the particular airline. You’d think with something that costly to them, because it comes down to a bottom line with the airlines or a business, that they would quite simply just not serve nuts. And yet that is not the case. And while I didn’t think that they served nuts as snacks anymore, it turns out, as a person who doesn’t typically fly first class, I found out from people who do that they do often serve warm nuts in first class still, and that just astounds me.

Kevin Pho: Now, you said that you got a lot of feedback after sharing your story online, and your story certainly resonated, with 2,000-plus social media shares. What kind of feedback did you get?

Samara Friedman: The feedback I got from people was generally very positive. They appreciated knowing this story and what concerns they may have to address, particularly if they’re physicians on a flight, including that they might not be able to find an auto-injector and that they may have to adjust dosages of things to figure out the right dosage of epinephrine to give someone.

I also found that there’s an app called FlightRx, and it lists the 23 most common flight emergencies, what signs and symptoms to look for, and what the treatment is, with dosages. I have now downloaded that app, so if I run into something where I do have an idea of what the medical issue is, but it’s not an allergy, where, again, my layman’s expertise lies, I might still be able to help somebody on a flight and know the correct dosages of medications, even though I don’t have an internet connection. So I think it’s a wonderful service to just have this app available for doctors who are in different specialties, other than the more primary care-related ones, to be able to help someone on a flight that they might not otherwise be able to help.

I also found that the AMA is now pushing for legislation to require auto-injectors on airplanes. As of 2022, they’ve made that an initiative. My concern, though, also in receiving additional information from people, is that there always seem to be loopholes. So about eight, 10 years ago, it was required to have automatic blood pressure cuffs on airplanes, because it’s very hard to hear through a stethoscope with that background noise, and my plane actually had that. But the last time I responded to an emergency on a plane, which was about six years ago, they did not have that. And I heard from other people that they’ve been on flights recently where they did not have that, and that there are loopholes in these regulations through which these airplanes are able to avoid the most recent and helpful recommendations. So that’s also a concern.

Kevin Pho: We’re talking to Samara Friedman. She’s a pediatric orthopedic surgeon, and she’s talking about her KevinMD article, “A nut allergy nightmare at 35,000 feet.” Samara, what are some of your take-home messages that you want to leave with the KevinMD audience?

Samara Friedman: So I think, first and foremost, that there needs to be more of a push for the airlines to be accountable for what they are serving. They have kosher-friendly meals and vegetarian-friendly meals. I don’t see why they can’t make an effort, for a lifesaving change, to have meals that are free of the top eight allergens, at least that much, whether it just be a fruit plate or something that these children, and now adults, can eat safely on an airplane. And why aren’t there auto-injectors, so that anybody, whether they have a medical degree, or an EMT license, or are a pharmacist perhaps, can help somebody on an airplane who’s having a medical emergency, where resources are probably more limited than in almost any other situation?

So these are things that are easy changes, but the airlines need to be pushed to do it. And if it means convincing them financially, if they don’t want to be good Samaritans about it, then whatever it takes, they need to make these changes.

Kevin Pho: Samara, thank you so much for sharing your story, time, and insight. Thanks again for coming back on the show.

Samara Friedman: Thank you so much.

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