Anaphylaxis – PediaCast 178

Topic

  • Anaphylaxis

Guest

  • Dr Daniel Scherzer
  • Pediatric Emergency Medicine
  • Nationwide Children's Hospital

Links

 

 

Transcript

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello everyone! And welcome once again to PediaCast, a pediatric podcasts for moms and dads. It is episode 178 for September 6th, 2011, and we’re calling this one Anaphylaxis, which is just a fancy word that means severe allergic reactions. So were talking about the kind of things like if you have a bee sting and you get lots of hives and have trouble breathing or peanut allergies, the real severe allergic reactions. And that's what's were going to talk about. And to help us out we have Dr. Daniel Scherzer to join us and we'll introduce him in just a minute.

01:05

Before we do that we want to remind you that you can get a hold of us easily, just go to pediacast.org and click on the contact link. If you have any show suggestion or a question for us or a comment, you can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That’s 347-404-5437. I also have to remind you that the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, call your doctor and arrange a face-to-face interview and hands on physical examination. Also, your use of this program is subject to the PediaCast terms of use agreement, which you can find over at pediacast.org.

All right, so Dr. Daniel Schurzer is joining us in the studio today and he is an attending physician with the section of emergency medicine here at Nationwide Children’s Hospital, and associate professor of Pediatrics at the Ohio State University. Dr. Scherzer’s clinical interests include promoting the practice of cost effective and common sense medicine and the appropriate use of laboratory and radiology resources. I love that! Isn't that great?

02:21

Dr. Daniel Scherzer: Yes, I thought of it because I’m a proponent of common sense.

Dr. Mike Patrick: Absolutely! I just, I love that!

Dr. Mike Patrick: He has helped develop a simulation center at Nationwide Children’s, which integrates a simulation techniques into the hospital educational curricula in safety culture and he participates in the doctor-patient relationship in Capstone Courses for the Ohio State University College of Medicine. So welcome to PediaCast, Dr. Schurzer.

Dr. Daniel Scherzer: Hi Mike!

Dr. Mike Patrick: Great to have you here. So what is a simulation center? What exactly is that?

Dr. Daniel Scherzer: So the simulation center provides the opportunity for healthcare professionals in training to practice some of the things that they are going to learn before they get to real patients. In other words practice on plastics as much as you can.

03:06

Dr. Mike Patrick: Yes, and we're talking procedure kind of stuff for the most part of here. So I remember when I was a medical student and resident, it was basically ‘see one, do one, teach one’. Do you remember?

Dr. Daniel Scherzer: Yes, the ‘see one, do one, teach one’ still makes sense philosophically that you learn by experience and watching other people of model behaviors. But we’ve changed the definition of one to mean a set, maybe a set of 50 practices a number of times before you really do it.

Dr. Mike Patrick: So what kind of procedures are we talking about?

Dr. Daniel Scherzer: So in terms of procedures, we're practicing lumbar punctures, inner way managements, such as providing ventilations with a bag on a mask or intubating somebody. We also practice vascular access. So people think about IVs for that. But in an emergency when you can’t get an IV in, you might need another method.

Dr. Mike Patrick: Right, something where you’re trying to get a central line and hit the right vein.

04:09

Dr. Daniel Scherzer: Yeah, or even easier is an intraosseous way.

Dr. Mike Patrick: Right, so you’re going into the bone to get access. And there are parents in their cars and exercising right now who are cringing.

Dr. Daniel Scherzer: Right, I know. It sounds pretty barbaric but in reality if somebody really needs it, it’s a very good thing for them.

Dr. Mike Patrick: Absolutely. And you mention lumbar puncture and parents would know this is spinal tap, and it’s something in pediatrics. Pediatricians have to know how to do. And so it’s nice that they can practice on plastic now because when I learned that someone's baby out there was my first spinal tap and unfortunately that’s where the simulation center comes in nowadays to really help folks practice.

Dr. Daniel Scherzer: Right, there has to be first time for everything and ideally it should be a piece of plastic.

Dr. Mike Patrick: Yeah, absolutely. Well, that’s very interesting thing. But we're here to talk about anaphylaxis. Once you define for the audience, just briefly what is the meant by the term anaphylaxis?

05:08

Dr. Daniel Scherzer: Anaphylaxis is the most severe type of allergic reaction. It’s characterized by more than one major system of your body being involved.

Dr. Mike Patrick: Right. And we’ll get into, specifically, what that looks like with each body system. But before we do that, what sort of agents typically cause anaphylaxis?

Dr. Daniel Scherzer: The most common triggers for anaphylaxis in kids are actually foods. Insect stings can do it, so can some medications, exposure to latex or radio contrast die can be triggers in other people.
Dr. Mike Patrick: Are there particular foods? I mean, obviously parents think a lot about peanuts. I guess that’s sort of the big one that comes into people’s mind, but there are other foods as well that can cause it.

Dr. Daniel Scherzer: Yes. Peanuts, tree nuts, which are actually chemically different than peanuts; one can be allergic to the other and not the other one.

06:05

Dr. Mike Patrick: So, almonds, walnuts, pecans.

Dr. Daniel Scherzer: Almonds, walnuts, cashews, shellfish and other seafood are a cause. For some people, milk and wheat could be a cause.

Dr. Mike Patrick: And so, when people are exposed to these agents that cause the severe allergic reaction, what kind of, at the chemical or at the tissue level, what exactly how does this happen?

Dr. Daniel Scherzer: Well, this is all about your immune system misbehaving essentially.

Dr. Mike Patrick: Yes.

Dr. Daniel Scherzer: Your immune system is supposed to work for you, supposed to identify enemies and get rid of them.

Dr. Mike Patrick: Right.

Dr. Daniel Scherzer: If your immune system targets the wrong thing and then also overreacts, and in this case the immune system is really doing both. Even if the food were a friend, or excuse me, or an enemy, it would overreact.

Dr. Mike Patrick: Right.

Dr. Daniel Scherzer: So it’s targeting the wrong thing and just going at it too strongly.

Dr. Mike Patrick: Sure. Now, a lot of people who have allergic reactions, let’s say they have it to a peanut and they’ve had peanuts before and suddenly they developed this allergy to it. Why is that?

07:11

Dr. Daniel Scherzer: It’s not clear. Allergies are somewhat unpredictable. It does seem that somebody had been exposed to a certain kind of food in the past and then all of a sudden they developed an allergy to it. It may be that they were slowly developing some sensitivity to it.

Dr. Mike Patrick: Sure. So, just at some point the immune system decides, hey, I don’t like this. This is a foreign material. I’m going to make antibodies against it.

Dr. Daniel Scherzer: Yeah. The immune system is pretty hard to figure out and there are a bunch of eloquent people called immunologists who are working on it.

Dr. Mike Patrick: Right. I asked emergency medicine physician to come in and talk about the immune response, and the reason for that is because I think it’s important for parents, ultimately, to understand how they handle this at home and you’re the guy for that.

Dr. Mike Patrick: So, let’s say that you’ve been sensitized to some allergen that’s going to cause a severe reaction. So the body recognizes it as foreign, makes antibodies against it, and at some point down the line when you have the exposure, the immune system cranks up, overreacts and causes these mast cells to release histamines, which parents have heard of in the term antihistamine.

08:22

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: With Benadryl as an example of that. So, these histamines and other chemicals that are involved, what kind of symptoms then do those cause with the anaphylaxis?

Dr. Daniel Scherzer: The one that people are probably most familiar with is hives.

Dr. Mike Patrick: Right.

Dr. Daniel Scherzer: That’s when somebody gets big blotchy, itchy rash all over.

Dr. Mike Patrick: Yes, absolutely. So, it’s itchy, it kind of comes and goes and all over the…

Dr. Daniel Scherzer: Yes. And it can last for a variable period of time. It’s pretty noticeable for the most part, and in that case it’s recognizable that there’s no allergic reaction going on.

09:03

Dr. Mike Patrick: Right.

Dr. Daniel Scherzer: About 20 to 30% of people won’t have skin involvement, those cases are a little sneakier.

Dr. Mike Patrick: Yes, sure. And you talked about more than one system, so if someone takes an antibiotic, let’s say, and they break out in hives but that so, let’s say, with penicillin, but that’s it. Then that really doesn’t count as anaphylaxis, correct?

Dr. Daniel Scherzer: Right. If you just have one system involvement, that’s usually not anaphylaxis unless it’s your blood pressure.

Dr. Mike Patrick: Right, right, or breathing.

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: If you stop breathing, that’s a problem. Yes. And usually, if your breathing’s involved you do have other symptoms too.

Dr. Mike Patrick: Right. So, okay, we talked about the skin, how would anaphylaxis look with other body systems?

Dr. Daniel Scherzer: There are three other major areas that can get involved. One is that your breathing can get tight, you can have whizzing, get short of breath. Somebody looks like they’re in respiratory distress.

Dr. Mike Patrick: Right.

Dr. Daniel Scherzer: The other major system is that you get diffuse dilatation on blood vessels. At any given time, your blood vessels have some tone to them. But if they open all at once, you don’t have enough blood in your body to fill them. And if you have an adverse reaction like this, you can get this abnormal dilatation of blood vessels and that lowers your blood pressure and you can go into shock.

10:23

Dr. Mike Patrick: Right. So with the blood pressure if that happens, then you’re not getting enough blood pumped up to the brain, you can go unconscious and you can have a stroke, have heart attack just kind of…

Dr. Daniel Scherzer: People can get faint, dizzy, look pale, feel weak. So you have breathing in blood pressure, also your GI system can get involved. For some people involves significant cramping, abdominal pain, nausea and vomiting.

Dr. Mike Patrick: Now, let say that these things are happening and a lot of times it is sort of out of the blue. Because if it’s the first time that you’ve had this reaction, you’re not expecting it and your child suddenly, you know breaks out in hives, has trouble breathing, perhaps passes out. What should parents do?

11:07

Dr. Daniel Scherzer: If that happens, you should call 911.

Dr. Mike Patrick: Absolutely. Is there anything else? Now, let’s say it didn’t pass out. [11:15] you may want to know CPR, which I think encourage everyone out there to take a CPR course with American Red Cross that kind of thing. But let’s say that they don’t actually pass out, they breakout on hives and they just have maybe a little bit of a cough or wheeze. They say their throat feels fuller. They’re having trouble breathing and trouble swallowing. What should they do then?

Dr. Daniel Scherzer: There is still fair amount of unpredictability with that. So someone who has hives and is indicating that they have difficulty swallowing or they feel like there’s something in their throat, “Mommy, I swallow a bug.” Or the breathing feels a little tighter. They’re wheezing. They just still get an emergency evaluation really quickly.

12:00

Dr. Mike Patrick: So they should still call 911.

Dr. Daniel Scherzer: Yes. It may turn out well but it could also progress.

Dr. Mike Patrick: Let’s say, they’ve called 911 and they need to do CPR. Are there any medications that they could… Again we’re not giving medical advice here, but just in general with the treatment of severe allergies, what kind of medications should parents be thinking about.

Dr. Daniel Scherzer: So when 911 arrives, they have the ability to provide oxygen if that’s needed. They can provide and IV and fluids if that is needed. And in terms of medications… The one medication, which is really known to make a difference, is epinephrine, which is really just the medical name for adrenaline.

Dr. Mike Patrick: And this is EpiPen, EpiPen Jr. that kind of thing.

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: So parents obviously if they’re kids has this reaction for the first time, they are not expecting it. They’re probably aren’t going to have an EpiPen at home. So they have to wait until 911 arrive to be able to get that medicine. But parents who have had an experience with this in the past, that’s really an important for them to have an EpiPen at home or at school so it can be used.

13:08

Dr. Daniel Scherzer: Yes, for like you said for some people the first time they ever find out that there is a food allergy is through this dramatic process of going through anaphylaxis out of the blue. For a lot of kids, they were already have been diagnosed because they’ve had problems with asthma or eczema. And because doctors know that this could be associated with food allergies, this may already have been evaluated to some extent, so they may have an EpiPen. Or of course if they’ve been through anaphylaxis before, they’ll have an EpiPen.

Dr. Mike Patrick: Let’s say they have a history of asthma, and they’re wheezing along with their allergic reaction. Would albuterol be advisable?

Dr. Daniel Scherzer: Albuterol will help with the wheezing. But if you feel that is more to it such as there is rash or there’s difficulty swallowing, or if you’re child also looks pale or weak or seems dizzy, then the albuterol by itself won’t cut it. So they need an EpiPen.

Dr. Mike Patrick: And then parents still need to call 911.

14:02

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: Don’t think, “Oh, I just can give him albuterol and they’ll get better on their own.”

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: They should call 911 first.

Dr. Daniel Scherzer: Yes, it’s pretty much simultaneous, you give the EpiPen then you call 911. You might call for your EpiPen.

Dr. Mike Patrick: Now what about we talked about this being mediated by histamine medicines or histamine for muscles and antihistamine. Is there a role for Benadryl, or for antihistamine medications?

Dr. Daniel Scherzer: Antihistamines can definitely help with the itch and some of the smothering symptoms after the emergency have been taken care of. So if someone is at an emergency situation, they have anaphylaxis or look like they may be heading that way, then they should get epinephrine.

Dr. Mike Patrick: And 911, Epi – those are the main things.

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: Now, OK so let’s say the parents do that. They call 911, they do have an EpiPen, they use the EpiPen and the reaction goes away. So they call and cancel 911 at that point?

15:07

Dr. Daniel Scherzer: It’s a good question. They may be lucky that the reaction may go away and may not come back. The problem is you can only know that looking backwards. At the time, there is no way you can know that. And the EpiPen, the epinephrine may wear off in 10 to 15 minutes, but the immunologic process is still going along and it may pop back up, and it can pop up back with a vengeance. It’s really quite unpredictable.

Dr. Mike Patrick: So they can have kind of a rebound sort of effect once the epinephrine wears off. So I guess, really they should not call and cancel 911. The 911 should still come, evaluate and probably though if it was a severe enough reaction that they had to use their EpiPen, I think 911 probably should transport them to an emergency room.

Dr. Daniel Scherzer: Yeah, absolutely 911 will do that and they will bring you to the emergency department.

Dr. Mike Patrick: So, OK, so let’s take a step further now. So, the emergency squad has arrived and let’s say that the reaction didn’t go away. They take you to the emergency department. Let’s say you show up here at Nationwide Children’s Hospital or any other children’s hospital or community hospital’s ER. What would parent what would you expect to that point?

16:15

Dr. Daniel Scherzer: We’ll watch you from a few to several hours. It’s hard to give an exact number here. We’ll guide as to watch you for six to eight hours. If you had what seems like a more mild reaction, maybe it really wasn’t anaphylaxis, may not watch you that long. We’ll usually give you steroids to… The evidence supporting steroids isn’t quite as strong as the evidence supporting epinephrine but nevertheless getting steroids early on seems to be associated with the reaction not coming back. It’s something called biphasic reaction in which the immune system takes another go at it several hours later. Steroids may help prevent that.

Dr. Mike Patrick: So the epinephrine is really to stop everything now and the steroids is to hopefully prevent hat rebound or hopefully prevent it from lasting as long, from immune systems sort of being robbed up for as long as a period of time.

17:11

Dr. Daniel Scherzer: Yes, the epinephrine stops to really bad part and buys your time.

Dr. Mike Patrick: Now, in a kid who really, I mean they crashed and they had the epinephrine, they look good now, but they really, I mean maybe they needed some CPR, some oxygen. To those kids obviously they’re going to be observed for a longer period of time. Wouldn’t you put an IV in as well typically?

Dr. Daniel Scherzer: Yes, if someone had a very severe reaction, we would watch them overnight. We put an IV into them in case they need other types of medications.

Dr. Mike Patrick: And do sometimes these kids needed to be admitted to the hospital to overnight kind of stay.

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: Now, one thing we can talk about here and obviously with this in medicine, there are a lot of risks versus benefit talks, so some of the topics that we’ve talked about before, there are certain medications that you use for them and then one of the things that we mentioned are what are the side effects of those medications because you want to make sure that you’re really helping someone and not creating another problem with your medicine.

18:12

Obviously, since this is a life threatening condition that we’re talking about here, there’s really… There’s not much risks that we wouldn’t you would make us not want to use epinephrine. But let’s still just discuss very briefly what are the side effects from epinephrine, steroids, Benadryl – the kind of medicines that you use to treat. What are the severe allergic reactions and anaphylaxis? What kind of side effects can parent expect?

Dr. Daniel Scherzer: One of difficulties with anaphylaxis that it may not always looks so bad at first. So if someone’s having an obvious case, then I don’t think anyone’s going to worry too much about side effects. They’re going to want to save this child’s life. What’s harder is when the anaphylaxis is in process. It can develop slowly and then it could over the clip.

19:02

In order to prevent that going over the clip, you have to give the epinephrine as the process is developing before the child looks really bad. And that’s when people are going to worry about side effects. So here I am I have this child who doesn’t look so bad but he is wheezing a little bit. He says his throat feels funny, I could see the rash but he’s awake and talking to me. Do I really need to stick a needle on his thigh and give him a potent medication for this?

The worse that is ever happen to a kid with a single shot of standard dose epinephrine is that they’ve had some heart palpitations. They could feel their heart beating. That goes away by itself and doesn’t cause any harm.

Dr. Mike Patrick: And you’ve never heard personally and I’ve never heard personally of anyone dying from an epinephrine injection. It doesn’t mean that it hasn’t ever happen because there is always one in… that very in [19:54 XX]

Dr. Daniel Scherzer: Yes. I don’t think it has ever happen that at least a child has died from receiving a single shot of standard dose epinephrine. But children have died from not receiving a single shot of standard dose epinephrine.

20:10

Dr. Mike Patrick: Absolutely. So then, when you’re talking risk benefit definitely is worth the benefit, I mean the benefit outweighs the risk in that situation.

Dr. Daniel Scherzer: Yes. It does seem hard to do what is going to feel like in aggressive action. But actually, there’s more risk in not doing it than doing it.

Dr. Mike Patrick: And if a physician felt strongly enough about this child’s previous allergic reaction to give them an EpiPen, you know, that’s pretty much permission for parents to use it.

Dr. Daniel Scherzer: Absolutely.

Dr. Mike Patrick: Yes.

Dr. Daniel Scherzer: And in fact, one of this we didn’t mention before is that part of your treatment is disposition planning. So before you go home, we will prescribe a new set of EpiPens for you.

Dr. Mike Patrick: Right. So the side effects of epinephrine are going to be rapid heart rate is the big one. And just to make it a complete discussion, Benadryl, for most parents know this, it makes you sleepy, right?

21:00

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: And behavioral changes too.

Dr. Daniel Scherzer: Yes. For very young kids, age two, maybe younger, some of them can actually get wired.

Dr. Mike Patrick: Right. And there a lot of parents to know about that as well.

Dr. Daniel Scherzer: Yes, but for most people it will just make them tired.

Dr. Mike Patrick: Right. And the steroid medicine behavioral changes can affect their appetite and sleeping, but pretty minor things.

Dr. Daniel Scherzer: Yes. The steroids are actually low-dose, short-course and typically don’t cost much in the way of identifiable side effects.

Dr. Mike Patrick: Right. Now, how can anaphylaxis be prevented?

Dr. Daniel Scherzer: The only proven prevention is to avoid those things that you know you’re allergic to.

Dr. Mike Patrick: Right. Now what if, let’s say you’ve never had a reaction before but a parent or a grandparent or an uncle have had anaphylaxis, so very severe allergic reaction to a particular thing, should that person avoid that their entire life?

Dr. Daniel Scherzer: I think you have to be careful about that. At least get tested for that allergen if testing is available, family history, as for anything can be suggestive. I’m not sure how strongly it’s associated with going down the line if a parent’s allergic to peanuts, will his child be allergic to peanuts. I’m not sure how clear that is, but at least consider it suggestive.

22:22

Dr. Mike Patrick: Sure. And they could always visit or get a referral to an allergist if they’re really concerned and they can do skin testing, blood testing, you know, to try to figure things out.

Dr. Daniel Scherzer: Yes.

Dr. Mike Patrick: So, I think we’ve kind of stepped through this whole anaphylaxis thing and I think that’s been great. What’s the take home here for kids, parents and school officials?

Dr. Daniel Scherzer: One of the toughest problems out there is, in fact, using the EpiPen when you’re supposed to. In this country, it’s estimated that maybe 200 or 300 people die from food allergy induced anaphylaxis. That number really should be zero, even though one in a million doesn’t sound like a lot, it shouldn’t be happening at all. And unfortunately, some of these cases have occurred with and EpiPen in reach.

23:16

Dr. Daniel Scherzer: People have been afraid to use it or they actually couldn’t find it when they needed it, or they didn’t know how to use it.

Dr. Mike Patrick: So, as a parent, you know, it’s easy. I mean, you understand it. Hopefully, a physician has educated you, like we’ve done here, that it’s important to use the EpiPen when the reaction first starts, especially it’s the type of thing that can progress to anaphylaxis. But when a kid’s at school, the school nurse, the teachers, coaches, they haven’t heard that from the kid’s doctor and they may be more hesitant to use the EpiPen. What do you say to those folks?

Dr. Daniel Scherzer: Yes. It certainly would seem like an aggressive thing to do to somebody else’s kids.

Dr. Mike Patrick: Yes, right.

Dr. Daniel Scherzer: I could see the reluctance there. Now of course, parents are now trusting you, the teacher, the coach or the school nurse to recognize a problem when it’s starting and to do the right thing. So I think that for most schools, they get their permission from the parents to use the EpiPen. So when a parent brings in an EpiPen, they also talk to the teachers or school nurse about how to use it.

24:29

Dr. Mike Patrick: Yes. And unfortunately though, in reality, a lot of times that talk is just a form that they’ve signed. I mean, it’s unusual for parents to have actually talked to the teacher, the school nurse, the coaches.

Dr. Mike Patrick: So I would just encourage parents out there to do that, that don’t let a piece of paper be the only communication that you have with the school about the EpiPen in the office; that actually talk to the teacher, talk to the coaches, the school nurse, personally, one-on-one and really stress that I give you permission to do that.

25:00

Dr. Daniel Scherzer: Yes. If you’ve brought in an EpiPen to your child’s school is because you’re worried about the possibility that this could happen. It’s not that likely, but it could happen and that’s why you brought the EpiPen in, and it only works if somebody uses it.

Dr. Mike Patrick: Yes. I wonder, and I don’t know this off the top of my head and you may not either, if there is any studies that have looked at kids who have their allergic reaction at home versus school and then outcomes. You know what I mean? Is it an issue that schools aren’t doing what they’re supposed to do?

Dr. Daniel Scherzer: That’s a good question. I don’t know if there is outcome data or what is it and when they have looked at. We do know that…

Dr. Mike Patrick: It’d be a good study though.

Dr. Daniel Scherzer: It would be. Thank you for that idea. We do know that there is quite a lot of variability in how well people know how to use EpiPens that there is a variation in competency when it comes to knowing when to use it and how to use it. This variation in competency has been seen in school staff and day care staff.

26:05

Dr. Mike Patrick: Sure.

Dr. Daniel Scherzer: Some people have it down and some people don’t.

Dr. Mike Patrick: Yes. And we actually didn’t talk about that. So, what is the proper way to use an EpiPen?

Dr. Daniel Scherzer: So first and foremost, you just have to know when to use it, to know what to look for. It helps to know the directions ahead of time and to have practice ahead of time. The EpiPen comes in a case; you take it out of its case. It has a safety cap on it; the safety cap has to be removed. You have to hold it in your fist, keep your thumb away from either end of it.

Dr. Daniel Scherzer: There is an action end. It’s an orange end, it’s shaped like a cone as oppose to the flat end, which is the safe end, and you have to go for the outer thigh, push it in until you hear a click and then hold it in, count to ten.

Dr. Mike Patrick: OK. So, it’s not a rapid release. I mean, with the system, it’s a slow release in so you can’t just do it and then pull it out.

Dr. Daniel Scherzer: Yes. So there’s a spring that pushes the epinephrine into the muscle and it takes somewhere between few and several seconds, so if you count to ten, then you can be sure it’s in.

27:09

Dr. Mike Patrick: Sure. Now, parents see, when they go to the doctor and their kid gets a shot or an IV, you prepare the skin, you put alcohol on the skin. Do they need to do that?

Dr. Daniel Scherzer: No, you don’t have to do that. You can actually provide the injection right through a pair of jeans.

Dr. Mike Patrick: All right.

Dr. Daniel Scherzer: It’s designed for that.

Dr. Mike Patrick: Good. All right. Well, I think this has been incredibly helpful to moms and dads out there. I want to thank you for stopping by. We’re going to have a couple of links in the show notes for you. One is to emergency services, a Nationwide Children’s Hospital. If you want to know more about the section of emergency medicine here, we’ll have a link there for you.

Dr. Mike Patrick: And then the food allergy and anaphylaxis network is a great resource for moms and dads about food allergies and support groups and resources, and so we’ll have a link at pediacast.org in the show notes.

Dr. Mike Patrick: By the way, we have a brand new website, redesigned. So, if you haven’t visited pediacast.org recently, please do. OK. So finally, when folks come by PediaCast, what we’re talking about now sort of the end of the interview, one of my passions is for families to spend time together outside of technology. So not just in front of the TV, in front of the computers, but actually doing something as a family. And board games is something I remember as a kid, always been a fun thing to do. So, we’re just asking each guest that comes by, what is your favorite board game that you remember from childhood or that you play now?

28:39

Dr. Daniel Scherzer: This is an easy question for me. I used to love playing Stratego. My sister and I can play Stratego all day.

Dr. Mike Patrick: I don’t think I’ve even heard of it, really. It’s Stratego.

Dr. Daniel Scherzer: It’s like chess for non-chess masters. It’s easier.

Dr. Mike Patrick: OK. Sure. Is it like Backgammon?

Dr. Daniel Scherzer: No. Less luck involved.

29:02

Dr. Mike Patrick: OK, sure. Stratego. Well, that is a new one. No one has mentioned that one before and you’ve aroused my curiosity, so I need to look that one up. All right, thanks again for stopping by. I really, really appreciate it.

Dr. Daniel Scherzer: Thank you.

Dr. Mike Patrick: So that’s Dr. Daniel Scherzer from the section of Emergency Medicine here in Nationwide Children’s Hospital. I’d like to thank him for stopping by, and of course thanks to all the moms and dads out there for listening in.

Dr. Mike Patrick: I want to remind you, iTune reviews are extremely helpful as well as mentions on your blogs, Facebook and your tweets and be sure to tell your regular doctor about PediaCast so they can spread the news to other moms and dads out there for us.

Dr. Mike Patrick: Again, pediacast.org, just go to the contact page and you can get a hold of me. You can also email pediacast@gmail.com. And again, we have a voice line. You can leave a message with a question or a comment at 347-404-KIDS. That’s 347-404-K-I-D-S. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.

[Music]

30:21

Announcer: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next on PediaCast.

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