Connecting "FA Action Plan" with "Asthma Action Plan"

[anonymous]

A lot of us have read the article "When Anaphylaxis Looks Like Asthma", which can be found at
http://www.aanma.org/pdf/AnaphylaxisGuide.pdf.  I have always given a copy of this article to schools and camps that have cared for dd (and I still will), but I wanted to document that my dd's doctors agree with the advice given in the article.  This is important to me because my dd has asthma symptoms much more frequently then allergic reactions, which I felt put her at risk since others tend to think of her asthma, not her FA, if she has respiratory symptoms.

So anyway, this is what I did.  I'm posting it here in case it will help others and also to see if there are suggestions for improving it.

________________________________________________________


There are 3 stapled "1 page" documents:

1.  Standard Food Allergy Action Plan

2.  Asthma Action Plan.  This was a standard form and there was not much room for changes.  However, in the "Yellow Zone" section, after it mentions the asthma rescue meds to be given, it then says if those meds don't work "in < 5 minutes, consider EpiPen".  I figured this at least gets whoever is watching dc to remember her FA.

3.  Separate note from pulmonologist.  It has some specific asthma instructions regarding dd.  It also has a paragraph connecting FA and asthma: 

       Snipped at request of OP.  See reply #7 for different wording.

I realize it's not perfect, but it is important to keep it simple for schools.  Allowing that 5 minutes on the asthma side is debatable, but she has symptoms a lot and they often don't resolve quickly.  I'm thinking of having the allergist modify the FA action plan to make a note that every minute counts in a FA reaction and it is important not to delay giving Epi if FA is
suspected.

I don't usually post exact wording like this, but I thought that this was important enough to share.

So, what do you think?

edited at request of OP.

[Mfamom]

Thank you for posting that!  I have also worried about people thinking a rx could be asthma.  Our asthma action plan says give epi if symptoms don't improve.

I've also let my ds know that epinephrine is an excellent asthma drug and that if he ever has asthma symptoms that don't improve with albuteral, to use it!

[anonymous]

That's interesting that you also have an epi as part of your asthma action plan.  It wasn't a part of dd's until I requested it.

I'm going to leave this here, but delete this id.  As always, of course, check with your own doctors about what is appropriate for your action plans.

[anonymous]

I just wanted to finish this.

I forgot that FAAN had a new format for the FA action plan that stresses Epi   

(Guests aren't allowed to post links - maybe somebody can post the FAAN FA action plan for me)

Very good.

Our allegist also wrote to give epi 1st (before asthma meds) in the event of a FA reaction.

[anonymous]

It's me again 

Did you notice that here

Any SEVERE SYMPTOMS after suspected or known ingestion:
One or more of the following:

they don't have "Gut" anymore?


They do have it in this section

Or combination of symptoms from different body areas:

hmmmmm

What do you think?

[LinksEtc]

(Guests aren't allowed to post links - maybe somebody can post the FAAN FA action plan for me)

http://www.foodallergy.org/files/FAAP.pdf

[LinksEtc]

Just FYI

Emergency Action Plan from the Food Allergy and Anaphylaxis Network

[anonymous]

I'm rethinking this and I'm not happy with the above wording.  (Maybe a mod can delete so nobody copies it)

Maybe this would be better?

As dd's pulmonologist treating her asthma, I wanted to make the school aware that the symptoms of asthma and food allergy anaphylaxis can be very similar.  If dd has signs of isolated respiratory distress (i.e. wheezing, cough, shortness of breath) and there has been a suspected or known ingestion of her food allergen, immediately refer to her Food Allergy Action Plan.  <Asthma rescue med> treatments are NOT sufficient for Food Allergy Exposure, but epinephrine will help treat either asthma or food allergy anaphylaxis.  If food allergy exposure is not suspected, then follow her Asthma Action Plan, but if symptoms are not improving, consider whether there may have been an unintentional food allergy exposure. 

Thanks for letting me think out loud.  I may refine more privately.  It's so hard because she has asthma symptoms so often and I don't want her epi'd all the time, yet if it is FA, it is so important to epi.  I like how the FA action plan explains that antihistamines and inhalers/bronchodilators are not to be depended upon to treat a severe FA reaction.  Maybe this will let those caring for dd know that her different doctor's are on the same page as far as treatment.

I'm just a confused FA/asthma mom.  Talk to your own doctors!!!

It would be nice to see a standard asthma action plan that takes into account the special considerations of those with FA as well as asthma.

[LinksEtc]

I'm going to put this link here also:

"Sudden Death: British High School Student's Case Raises Questions"
http://www.asthmaallergieschildren.com/2012/01/11/sudden-death-british-high-school-student%E2%80%99s-case-raises-questions/

Regardless, whether this was a case of food allergy anaphylaxis or asthma or both epinephrine is the best emergency treatment for both kinds of airway constriction, but the double duty makes prompt use even more critical.

-----------------

ETA - Linking to this thread which is a continuation of this discussion (page 2 has a pic):

Standard Protocol for "Asthma Action Plans"

[CMdeux]

bumping for some new members-- also linking to our other related thread:

Re:  Grab her inhaler! That LOOKS like an asthma attack! Oh, oops . . . anaphylaxis:

[jschwab]

Thanks for posting. We just lost a student here in the district. They never even called 911.

[Macabre]

Jschwab can you post--or PM me if you want privacy--any news articles about this? I am dealing with a similar situation and that article could be helpful to give for school.

[CMdeux]

There have been two fatalities in WA that were very likely the result of delayed treatment due to presentation as asthma--


Nathan Walters

and another one-- Amaria/Ammaria??  (Can't think of the name-- but it was in the greater Seattle area within the past several years-- happened at the very start of the school day.)

[Macabre]

Ammaria was Virginia.  She was given a peanut at school.


I did find the example Jschwab was referring to. It doesn't seem FAs were involved 

[CMdeux]

MERCEDES.  Mercedes Mears. 
That was her name.  Her parents sued.  She was ten-- and died from probable anaphylaxis-- Spanaway WA/Bethel school district in Washington State. 



This is a full article clip from a cached news article:  I've bolded portions for emphasis.

[spoiler]

Fifth-grader Mercedes Mears lay gasping for breath on the health room floor at Clover Creek Elementary School.

"I'm gonna die," she said.

Four school employees gathered around the dark-eyed, gap-toothed 10-year-old, giving comfort, working to calm her, urging puffs on an Albuterol inhaler, reports show.

But Mercedes' asthmatic lungs were unable to pump oxygen. Her 94-pound body went into convulsions.

When medics arrived at the Spanaway area school, she was in "full arrest," their records say.

Less than an hour later, she was dead.

Bethel School District officials call her sudden illness and death on Oct. 7 sad and say they grieved the loss.

Mercedes' parents, Mike and Jeanette Mears, call it negligence.

Last week they filed a $15 million legal claim against the district, charging that staff members were ill-prepared to handle the emergency. They say staff failed to administer potentially life-saving medicine kept in the very health room where the girl died.

"I don't feel they did everything they could to save Mercedes," Jeanette Mears told The News Tribune. Her "angel girl" with the megawatt smile, beaded cornrows and tiny jewels in her ears would be alive today if a school staff member had snatched up the EpiPen with Mercedes' name on it and injected its contents into her thigh, Jeanette Mears believes.

No one at the school performed CPR on the child before paramedics arrived, Pierce County Medical Examiner's Office investigator Amber Midkiff-Bray wrote in her Oct. 8 report.

Doctors pronounced Mercedes dead following a 20-minute Medic One ride to Mary Bridge Children's Hospital. The Medical Examiner's Office ruled she died of an overwhelming asthma attack.

Dr. Lawrence Larson, a pediatric allergy specialist who is one of Mercedes' doctors, told detectives "he had only seen one other case of such severity in 31 years of medicine," the police report said.

The district won't comment on the case or answer specific questions about it because it's a legal matter, spokeswoman Krista Carlson said.

Lance Hammond, a litigation specialist with risk managers Canfield & Associates, said only that he is investigating the circumstances as part of the district's coverage through the Schools Insurance Association of Washington.

CLAIM QUESTIONS CARE

The claim is a precursor to a lawsuit; if it's not settled within 60 days, the family could take its case to Pierce County Superior Court.

The claim charges that school staff failed to follow Mercedes' "valid care plan in place in case of situations involving sudden and severe respiratory symptoms, such as wheezing, shortness of breath and difficulty breathing."

Mercedes' care plan, the claim says, was signed by a school nurse on Aug. 29, "just five weeks prior to Mercedes' death."

There was no school nurse in the health room the morning Mercedes died. Schools don't routinely have nurses on site, as they rotate between buildings.

On Sept. 24, two weeks before her death, a fresh Albuterol inhaler and EpiPen were provided to the school, the claim says.

Larson prescribed the EpiPen, an injectable dose of epinephrine, for an allergic emergency, records show. Mercedes suffered both food allergies and asthma.

A care plan prepared by school nurse Heidi Christensen notes Mercedes "has Benadryl, an EpiPen and an inhaler in the health room," and lists Larson's name and phone number.

Larson's orders don't stipulate the EpiPen must be used in an asthma attack, but the family's attorney, Thaddeus Martin, believes it would have saved her life. He describes it as "adrenaline to be used in emergency situations when Mercedes had breathing difficulty."

Since a nurse signed the plan, Mercedes' parents believed a school staff member with health training would know what the medication would do and would administer it in a crisis, he added.

Martin maintains that school officials should have been better prepared to deal with an emergency involving a student with known asthma, frequent visits to the health room to get puffs from the inhaler, and many absences due to the illness.

Mercedes was given inhaler medication at school the day before her death, records show.

The claim also contends that the school's health clerk – a former lunch server, playground supervisor and office worker with no formal medical training – escorted the wheezing Mercedes, who said she couldn't breathe, from outside the school to the health room. The health clerk called 911 from there.

State law requires every school district to adopt policies regarding "asthma rescue procedures."

Bethel has plans in place for administering student medications, protocols for handling emergencies and asthma rescue instructions, Carlson said.

Health clerks must be high school graduates and have a current CPR card, Carlson added. They also receive on-the-job training from the school nurse and other staff and attend monthly meetings for additional training. But she didn't know last week what training or credentials the clerk on duty that day had.

The 17,500-student Bethel School District has the full-time equivalent of 11 school nurses and five licensed practical nurses on staff, Carlson said. Each elementary school gets 1 to 21/2 days a week of nursing time.

The practice of having a nurse on every campus has fallen victim to other priorities, said Cheryl Sampson, president of the School Nurse Organization of Washington.

BREAKDOWN IN THE SYSTEM

Though she couldn't comment on the specifics of the case and did not assign blame to any person or entity, Reva Wittenberg, asthma program manager for the state Department of Health, called Mercedes' death "a really tragic example of a breakdown in the system of care for a person with asthma."

The death illustrates that asthma is a serious disease with deadly potential, she and other experts say. More than 20 million Americans suffer from asthma, and more than one-quarter of those – 5.5 million – are children, according to the American Lung Association of Washington.

"Every four days, someone in Washington state dies from asthma," the association's Web site says.

The patient and everyone in the immediate circle of a person with asthma should take a proactive role in their care and compliance with medications and treatment, Wittenberg said.

"All school and childcare providers must be alert to symptoms that may indicate asthma and have policies in place that help staff to assist children with managing asthma," she added.

THE DEATH OF A CHILD

Mercedes Mears stepped out of friend's car and onto the grounds of Clover Creek Elementary School around 8:15 a.m. that day last fall. Almost immediately, she began having trouble breathing and sat down on a bench.

Her sister Jada, who was 9 at the time, ran for help, accounts of school staff members and the medical examiner show.

The health clerk walked Mercedes into the building and called 911, according to a chronology of events later compiled by the district's assistant director of human resources.

The clerk's voice was calm in her 8:22 a.m. call to 911, when she told a dispatcher, "I have a student who has asthma and she's complaining that she can't breathe."

She clearly recited the school's phone number and address. A child can be heard screaming in the background.

Three other school employees came to Mercedes' aid, their written accounts say.

They describe a chaotic, chilling scene in which a clearly distressed Mercedes was crying and gasping for air. As the four adults tried to get the child to relax, one of them gave Mercedes doses from an inhaler "telling Mercedes to try and hold it in" the accounts say.

The flailing child knocked the inhaler away during one attempt.

At some point, Mercedes lay down on the floor, said "I'm gonna die" and then apparently became "unconscious," medical investigator Midkiff-Bray wrote in her report, which was based on interviews with witnesses.

The health clerk told Midkiff-Bray she didn't know whether Mercedes was breathing and that no CPR was done.

School Principal Don Garrick later told the investigator, "We are not medical people."

Medic 60 arrived at the school at 8:28 a.m., about six minutes after the 911 call, according to records from Central Pierce Fire & Rescue.

"Arrived to find patient supine on office floor unresponsive," the medics' report says. They instituted advanced life support measures.

"Cardiac arrest," reads a one-line notation at one point in their log.

As they suctioned Mercedes' airway, she vomited.

At 8:37 they were en route to Mary Bridge. Their log shows no heart rate or blood pressure as they administered oxygen, epinephrine and other drugs at the school and in the ambulance.

At 9:09 a.m., doctors pronounced dead the girl who loved to roller skate and eat pizza, the child simply called "'Cedes" – pronounced Say-Dees – by many who loved her.

Jeanette Mears thinks she put too much trust in the school, believing "someone with credentials would be in the nurse's office."

"She was funny, she was sensitive, she was serious," Jeanette Mears said of her daughter. "She was an angel."

Read more here: http://cc.bingj.com/cache.aspx?q=allergy+asthma+death+Washington+elementary+student&d=4614960761670284&mkt=en-US&setlang=en-US&w=WPreoSTEijgypFsRcEpBLSJxk2v_ENOh#storylink=cpy[/spoiler]



I think this points to some serious issues getting OTHERS to even follow an anaphylaxis treatment plan when they think that they are dealing with "just asthma."