Lions and Tigers and Peanuts, Oh My!

I just spent two weeks volunteering in Tanzania, Africa through a company called EDU Africa.  For sure there will be other posts describing the work we did and the impact being in Africa had on me, but I'm just starting to process those thoughts at this point.  Intertwined with our volunteer work were various cultural immersion experiences - learning some traditional African dance, tasting African cuisine, a canoeing trip where we were able to see many of the birds native to East Africa, and we finished our visit with a two-day safari. Who would have thought that after two days on safari where an elephant crossed the street right in front of our tour vehicle and we saw several prides of lions close enough to take my breath away - that a peanut would be the most deadly thing we would encounter on this trip... but alas, it was! This post is about one of my fellow volunteers experiencing an anaphylactic reaction to peanuts on our last night in Tanzania, some stats about anaphylaxis, and what to do if you find yourself in this situation.

Rice, Stew, and Ugali.  Photo: KConn

Prior to our arrival in Africa, the EDU Africa staff gathered each volunteer's dietary concerns.  The company organized almost all of our breakfasts and dinners at our hotel as well as providing us boxed lunches at our volunteer sites each day - interesting meals such as spicy carrot sandwiches and tomato paste coated french fries or cooked meat/vegetable dishes flavored with curry eaten using ugali - a traditional African corn-based dish that reminded me of polenta but that you roll up into a ball and depress a divot into it and basically make yourself a tostito scoop to gather up the stew.  We also had the opportunity to order off menus at a few restaurants which was a constant adventure... I tried to get mozzarella sticks at a restaurant called Bravo Pizza but the mozzarella sticks were basically limp string cheese rolled in dough that was floppy...more like the consistency of soggy fish sticks and were mostly good for a few laughs.  Because there is a high risk of water contamination with parasites, we were strongly advised to avoid consumption of fresh fruit (unless you can peel it like a banana) or any fresh vegetables (because of them being washed in the unsafe water), so there were a lot of carb-heavy meals and cooked vegetables and potatoes and eggs.

With regard to food restrictions, our group of 7 people had several.  For me, I have a strawberry allergy that, to my knowledge, is not very severe - though after this experience, I can guarantee I'll be getting that re-checked.  I also don't eat red meat - but had told them I didn't eat beef, so when pork chops were offered to me, I requested a vegetarian meal along with a fellow volunteer who is a true vegetarian. We had a member with a gluten allergy - try explaining that in Kiswahili - the official language of Tanzania - repeatedly - when they don't know what gluten is.  They use a lot of corn and rice, but to be certain that wheat wasn't in any of the foods was impossible.  And lastly, we traveled with a young woman with a severe nut allergy - who despite her constant efforts and a group of people looking out for her - managed to consume nuts on our last night as they were in a chicken dish with curry that had no evidence of hidden poison.  She had identified her allergy to the hotel, but whether a language barrier was the problem or the serving staff being unaware of what was in the food - it didn't matter. So... we had just finished our second day of African safari and are in the middle of Tanzania in a town I don't know the name of, when we were faced with a potentially awful situation.

Fortunately, there were seven of us PT students and PTs and, after seeing us run out of the dining hall to get closer to her EpiPen and medications, an Australian resident physician joined us and provided her recommendations, which ultimately led to our new friend of two weeks spending the night in a Tanzanian emergency room getting doped up on corticosteroids.  

I'll start with what you should do if you already know you have an allergy to which you have an anaphylactic reaction and you come into contact with the allergen.  In this case, you should have a prescribed EpiPen, which contains epinephrine, also known as adrenaline.  Epinephrine is a medicine that increases your heart rate, helps improve breathing, reduces swelling and hives, and can increase a dropping blood pressure.  Our friend knew she had the allergy but had never had to use an EpiPen because her previous exposure was her first and resulted in a trip to the emergency room home in the USA, ultimately resulting in her carrying an EpiPen and avoiding nuts at all costs.  She hadn't used an EpiPen yet, and there is always risk of having a negative reaction to an EpiPen, in addition to the reaction  you're already having to your allergen.

Our travel buddy had four EpiPens on the trip with her, but only one available while we were on safari, the others packed away in the city with the rest of our luggage.  After she started noticing symptoms, she immediately went to her room and decided to try antihistamines first, wanting to avoid use of the EpiPen.  Truthfully, it delayed the inevitable, though at that time we didn't have our driver on-site yet so it was a good thing that she delayed using it.  About 30 minutes after ingesting the nuts, her symptoms started to get worse.  She threw up her dinner, started breaking out in hives, began to cough and having some difficulty breathing.  Wanna know what happens when you start having trouble breathing?  You panic.  The major problems with anaphylaxis are that it can elicit constriction of your throat, which can be a medical emergency, as well as dropping your blood pressure, which can make you pass out.  Fortunately, our group acted quickly and had initiated the emergency chain to get our driver back to our hotel to be ready to take her to the hospital once things progressed - which they ultimately did - and the hotel manager contacted the nearest hospital to alert them of our situation.  When the Australian medical resident checked her out, and a transport was ready, she was ultimately given the EpiPen and taken to the hospital.  It was a scary situation for about two hours while the rest of the group remained at the hotel waiting for updates on her status, but the end result was a sore arm from weird techniques of placing an IV with a big bolus of corticosteroid making her sore.   Our terrible situation worked out in the best possible way.  Our friend is fine, and now knows what it's like to have to use her EpiPen.

But what if you don't know you have such a severe allergy?  If you find yourself in a situation where you think you have eaten something that could be causing anaphylaxis, the first thing - and also the most difficult - is to try to remain calm.  Panic and increased heart rate don't help if you're experiencing restrictions with your breathing.  Find someone to help you, so you're not alone, and start the emergency chain ASAP.  Either call 911 for an ambulance or get to the hospital quickly.  Anaphylaxis generally does not stop on its own, though it may seem to take a pause and then later return, which can be misleading and cause more trouble if you decide to delay getting medical attention.

According to this website from the American Academy of Allergy, Asthma, and Immunology,
(AAAI) anaphylaxis can be fatal, particularly if there is a decrease in blood pressure, difficulty breathing, or loss of consciousness.  Our friend definitely had difficulty breathing and was coughing by the time she left the hotel to go to the hospital.  We kept an eye on her pulse - but did not have means to check her blood pressure.  The most common causes of anaphylaxis are foods (all different types of nuts, fish, milk, eggs, and preservatives), medications (particularly antibiotics and anti-seizure medications), and insect stings.  In some cases, exercise can induce anaphylaxis, and there is a correlation between those who experience anaphylaxis and those who have asthma, as both tend to present with similar respiratory complications.  The AAAI site advises that if you have a reaction, you should always go to the hospital - even if you feel improvement in symptoms with your EpiPen or another medication.  EpiPen treatment is for emergency response in order to get you to the hospital for appropriate care.  They tend to last around a half an hour, though they may only last ten minutes, so people often carry more than one, particularly if they'll be far away from medical care, so that they can re-administer if symptoms worsen as it weans off.  EpiPen should be administered to the soft outer portion of the thigh and can be done through clothing.  It should be held in place for about 3 seconds and has an indicator on it that changes color to let you know that the medicine is being administered into the body.  Once an EpiPen is used, it cannot be re-used.

And so, the scariest part of my African adventure was a peanut.  Though there are no tigers in Africa, which this article explains, so if I had seen one on this trip, it probably would have scared me quite a bit, too.

The Government is After Me!

Photo Credit: Michelle Vieira at London 2012 Olympics

This morning I have a long layover at JFK airport en route to Africa!  As I've been observing TSA, watching the news sitting in horribly uncomfortable chairs, and seeing what's going on in the world, it got me thinking a little bit about our government. Earlier this year, I was home in Connecticut visiting my family when I received a letter stating that I had been selected for Jury Duty.  In the State of Connecticut.  Where I have not lived for the past 4.5 years.  Fortunately, it was easy for them to verify that I no longer live there and was able to get out of it - but that's my second Jury Duty Selection and some people have never been picked!  How does this happen?  What fortunate - or unfortunate - thing have I done to put me on a list saying I should serve when others have not been chosen?

My first jury duty selection was in the summer of 2004, right after my freshman year of college.  It was a trial where a man had been running in the early morning and he had been struck by a car resulting in severe, long-lasting injuries.  The runner was suing the driver of the car, who happened to be the newspaper delivery guy.  He was also suing the newspaper company and their insurance company.  I spent 5 days in the New Haven County Courthouse listening to testimony, reviewing medical bills and photos of the injuries. This was long before I was a physical therapist, so while I was a bit annoyed to be missing my summer vacation, my job paid me for the time and it was definitely a better learning experience than being at work in the bakery at Everybody's Supermarket would have been.

Anyways, I returned to Seattle after a great snowy East Coast trip and arrived to find a letter from the State of Washington Department of Health that my PT License was being audited and that I needed to show proof of all of my continuing education.  I was certain the government was out to get me!

So... for my fellow PTs - in or out of Washington State, here are a few pointers, should this happen to you, because I found the letter indicating my audit - and the details of what was needed- to be quite lacking.
1) Keep track of your continuing education!  Names of courses and the presenters, dates and locations of where you took them, number of hours, a list of objectives for the course, and keep the copies of the certificates.  My certificates are in a binder and I have a google doc with my annual course titles/hours already, but I didn't have all the required information that was asked of me.  For example, I've talked about the courses I took with Mike Reinold and Lenny Macrina a few times on the blog like here and here, but I couldn't have told you their credentials and didn't have access to written objectives for the two courses I took from them.  Fortunately, their credentials were listed on the certificates and they were more than willing to send me a list of objectives since their classes have been approved by continuing education review boards.  Medbridge also supplies all this information on all of their certificates.
2) Know the rules of your state.  Washington does not require verification of your courses for PT.  Neither does Connecticut.  Three states (Maine, Massachusetts, and South Dakota, which I wrote about here do not require continuing education at all.  But if you practice in those states and then try to switch states, this may cause you some problems in transitioning your license elsewhere. (Also- how are you practicing physical therapy without participating in continuing education?!? My education was great at UConn but seriously- you’re left needing to know so much more!) You may have specific things you need to have specific education for, varying by state. Examples of unique circumstances that some states have for continuing education:

• Suicide prevention training - required in Washington, course is available on Medbridge - probably a really good thing for any physical therapist to have!
• Spine manipulation - can get a special endorsement in the state of Washington, which I hold, and which has its own continuing education requirements. If I had to guess, this is the reason why I was audited... but maybe it's just random.
• Dry Needling - not permitted in Washington, but is allowed in many other states.  My understanding is that dry needling certifications tend to be regulated carefully in some states.
• Somewhat related - if you are a Certified Strength and Conditioning Coach through the NSCA, you cannot use almost any physical therapy courses for your continuing education for your CSCS.  They have a list, here, which includes First Aid/CPR as an option - which we cannot claim for continuing education for our PT licenses.

If you're in Washington, the letter for audit basically says you should read the laws and see what applies to you and submit sufficient information to cover your own requirements.  Here's where you would go to find that information:

1) Physical Therapy Requirements: here for your initial license and here for continuing education requirements

2) Spine Manipulation Endorsement Requirements: here
3) Dry needling is not permitted in the state of Washington under the Physical Therapist practice act,, so we don't have regulations for it. 

I asked a lot of PTs if they've ever been audited... zero coworkers or PT friends have been, but some had friends or family members who've had to submit their information.  Overall, the process wasn't really that difficult because I have all my certificates and track my hours - plus I have more than enough hours for everything I need.

Ultimately, this is my PSA that you should keep track of - at the very least - the minimum requirements you need for your license to remain active - because this is a real thing and to track those things down later would have been much more difficult. 

Abby 2 - Government 0.   See ya in two weeks, America!