An (Epi)Pen That is Mightier than the Sword

Man down.

It’s a typical Thanksgiving family get-together. But within ten minutes, your great-uncle takes a stab at the interesting looking sesame salad located behind the steaming sweet potato pie. Immediately after tasting it, his throat starts to swell, his skin becomes itchy, and it becomes increasingly harder for him to breathe. Moments later, he is passed out on the floor. A life-threatening anaphylactic reaction has begun.

Unfortunately, your great-uncle does not carry around his EpiPen with him at all times. Perhaps there is an expired EpiPen sitting at the bottom of his bookcase collecting dust. But that isn’t going to cut it when his air pathways are constricting at a rapid pace and his blood vessels are dilating.

Your great-uncle is not alone in neglecting to carry his EpiPen despite his severe food allergies (in this case, apparently sesame), and his doctor’s advice. Even if the EpiPen is on-hand, many people do not know how to use it. Dr. Talal Nsouli, a fellow of the American College of Allergy, Asthma and Immunology said, “a recent study found nearly 75 percent of people who own an EpiPen have no idea how it actually works, so training school nurses, teachers, coaches and even allergic kids themselves is key.” He emphasized the importance of carrying an EpiPen after Cameron Espinosa, a 13-year-old Texan, died after a fire ant bite and was himself without an EpiPen.

So what is contained in this life-saving EpiPen device, and how does it work? The EpiPen is actually the brand name of an auto injector that contains one dose of epinephrine. This medication will counter the effects of a severe allergic reaction or, most commonly, the life-threatening anaphylactic reaction.

Flickr | Greg Friese

Flickr | Greg Friese

Each auto-injector contains one dose that must be injected into the outer thigh. After using the EpiPen, it is advised that the person with the allergic reaction go to a hospital emergency room immediately. This is a cautionary measure in case the person may need further treatment, or if another follow-up allergic reaction occurs.

The EpiPen is not a device that deserves the role of a dust-collector at the bottom of your bookcase. Actually, the EpiPen has been the number one prescribed epinephrine auto-injector for 25 years.

Interestingly, the EpiPen is actually modeled after a military device. Shel Kaplan, a former Jewish NASA engineer is the inventor of the EpiPen (he passed away in 2009). The military once used a self-injecting device to combat nerve gas and other agents, called the ComboPen. Originally, Kaplan created the ComboPen specifically for the military. But in 1965, Kaplan began to create the EpiPen, patented it in 1977, and in 1980, the currently ubiquitous device became available for use by people with severe allergies that cause anaphylaxis.

The EpiPen is made in a regular size for adults and in a specialized size for children. Most doctors recommend that it should be used at the start of a life-threatening reaction in which the person has a variety of symptoms that affect the body. Symptoms of an anaphylaxis reaction include: flushing and itching skin, appearance of hives, swelling, rash; itching of lips, tongue and palate; swelling of lips, tongue and back of throat; and itching, redness, swelling, and tearing of eyes. In a more extreme reaction, coughing, shortness of breath, wheezing, dizziness, passing out, and a weak pulse may also occur. The anaphylactic reaction occurs when antibodies of the immune system create an exaggerated reaction toward a normally harmless substance, like food. After secondary exposure to the allergen, the body will produce large amounts of the protein histamine, which causes the characteristic symptoms.

Flickr | Hokkaido-Brit

Flickr | Hokkaido-Brit

The most common foods that cause an extreme or anaphylactic reaction (also known as the “big eight”) are eggs, fish, milk, nuts from trees, peanuts (groundnuts), shellfish (including shrimps, mussels, and crab), soya, and wheat.

Flickr | whatleydude

Flickr | whatleydude

A life-threatening allergic reaction can also occur to people with allergies to medications like penicillin, or to bees, ants, and ticks. It is also possible to have this reaction to exercise, or to exposure to cold, heat, or sunlight.

According to the American College of Allergy, Asthma & Immunology, food is the most common trigger for extreme anaphylactic reactions. However, stings from insects, such as the fire ants that stung Cameron on the school football field in Texas, cause about 500,000 emergency room visits each year, and approximately 40 deaths.

The advice to a highly allergic individual should be painstakingly clear. The importance of the EpiPen as well as the ability to access it combined with the knowledge of how to operate the device cannot be overstated. Frequently, once an allergic reaction is triggered, time is extremely limited. Therefore, the person may die in the process of trying to obtain an EpiPen or in the travel to the nearest emergency room.

Fortunately, Dr. Anna Nowak-Wegrzyn, an allergist at Mount Sinai Hospital in New York City, said that “Death from anaphylaxis – a severe, whole-body reaction to an allergen – is rare, killing about 400 Americans each year.”

Yet by no means should one treat severe allergies lightly. As Dr. Nowak-Wegrzyn said, “Even though deaths from anaphylaxis are, fortunately, rare, any death could be preventable.” Cameron’s mother also said, “My baby could be here if there were more trained personnel on the field… an EpiPen or something could have saved him, at least.”

So, a word to the wise for the highly allergic folks among us: carry an EpiPen. Know it. Learn it. Live it.

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Dahlia Pasik, "Almost" MD

Dahlia Pasik grew up in Long Beach, NY, a few short blocks from the beach. She graduated with a Bachelors in Biology from Stern College of Yeshiva University NY, NY and is currently an MD Candidate of the class of 2020 at Technion American Medical School in Haifa, Israel - where she gets to enjoy a local beach there as well. Aside from her constant indulgence of living in beach towns, medicine has been her calling since elementary school, and she looks forward to fulfilling her dream of healing the world.