Jay Fox's Dining Guide
FOX: IT’S TIME TO GET SERIOUS ABOUT FOOD ALLERGIES
“You are what you eat. For example, if you eat garlic you’re apt to be a hermit.” — Franklin P. Jones
OVER THE 25 YEARS THAT I’VE BEEN WRITING this column, a goodly number have included comments and instructions about dealing with food allergies and dining out. It’s now time to get serious. G (My wife Georgia) had an episode. A very serious episode.
I’m not going to give you any specifics or even tell you where it happened, because, while the restaurant staff committed some very serious blunders, it can happen in any restaurant. Most restaurant staff is not properly trained to deal with the issues of allergic reactions, and diners do not take proper precautions to help themselves avoid potentially deadly reactions. And while the folks at this restaurant were extremely upset by the event, it could happen again.
G and I took a long weekend drive across the state to see the gorgeous scenery that our visitors enjoy so much but which we take for granted. We visited several quaint old Colorado towns and checked out some restaurants known for fine dining but were new to us.
This was one fine restaurant. The views were beautiful, the rooms were beautiful, the food was exquisite, and the service was first rate. When we were first seated and greeted by our W, G told her about her allergies. She is extremely allergic to nuts and cilantro. The W made a note and told us that she would double check with the chef about each dish and be sure that there was neither in any of our dishes. That added note was necessary because often, even though we are all aware of our own allergies, we sometimes forget for just a moment, and we share or exchange dishes. Not so much between G and I, but we have a granddaughter who is also allergic to nuts and she always tastes everyone’s dinners cuz she loves everything.
After a leisurely and lovely dinner, my thoughts turned to dessert. While G rarely eats dessert, when we’re at a new restaurant, we try lotsa things just so I have enuf to write about, and while I don’t always know if I’m going to write a column about any particular restaurant, I knew that I would write about this one at some time. And since our dining experience up to that point had been almost spectacular, the tasting of at least two desserts was in order.
G ordered berry cobbler and I had apple pie. G was diving into her dessert when all of a sudden her face froze. She sed, “I think I just ate a walnut.” She called the W over and asked. The W had a concerned look on her face and headed straight for the kitchen. She came back even more worried. “The cobbler has walnuts.” Uh oh. So now what? G had inadvertently eaten nuts before with little or no reaction. On one occasion she ingested walnuts in a salad at a banquet. Her face had swelled, but an antihistamine had fixed that problem.
The manager came quickly, also quite concerned. No one knew why the baker put walnuts in the cobbler and at that point I didn’t care, but therein lays another warning. You never know what’s in any dish unless you ask the person who made the dish. Cuz chefs are sorta crazy people who do weird things. They’re always “creating.” You may never ever find walnuts in a cobbler; it’s not a typical ingredient. But there are just under a million cooks and chefs in the U.S. and you can bet anything that some cook will put nuts into everything.
Since we were in a resort town with the nearest hospital some distance away, I suggested we sit there and see if she had a reaction. Otherwise, we could be in the middle of nowhere with no cell phone service. We sat a bit. G got antsy and wanted to leave. The manager told us that there was a service station in a nearby town and they would probably have an antihistamine that G could take, so off we went.
G has had food allergies forever. She is allergic to many food items, but primarily, and most seriously, to nuts and cilantro. She invariably tells every server that she has those allergies. She carries a medic alert tag and an “epi” (epinephrine) pen wherever she goes. But she has never had a serious allergic reaction in a restaurant. Until now.
We arrived at the service station just prior to its closing. I ran in and kinda screamed that I needed an antihistamine and the clerk who was waiting on two customers quickly pointed to a box on the shelf. I ran out and gave G two tablets and water. Then it happened. She started into shock. Even tho G knew exactly what to do, she was in shock and unable to give herself the injection. I saw her condition and I sorta went ballistic to the point I’m too scared to give her the injection. I went into the service station and asked the wonderful, awesome, calm lady if she had ever administered an injection. She sed that she’s never done it but she probably could, took the epi pen from my obviously shaking hand, scanned the very simple, clearly written instructions on the pen, and gave G the injection. Very simple. Then she called 911.
We’re in a relatively remote area of Colorado. Emergency services are provided by volunteers. Those of you city dwellers who are served by professional paramedics and firefighters should know that rural Colorado has terrific volunteer emergency services.
About 30 seconds later, a car pulled up right in front of my car, and a lady jumped out. I don’t know who she was or what her position was, but she was one of several who received the 911 call and came to do what she could. She saw that G was breathing fairly well having been given the injection and told us that the paramedic and the ambulance were less than two minutes away.
About 60 seconds later two men arrived in a pickup truck. The paramedic jumped out with a medical bag and did his thing. The passenger jumped out with a two-way radio in his hand and began talking to an ER doctor at the nearest hospital — about 50 miles away. I stood back, still in some sort of shock and let them do their thing. The paramedic gave G oxygen and checked her vital signs while the second guy relayed the information to the ER doctor. They asked questions of both of us: G’s name, age, condition, allergy information, details of the incident, had an epi pen been injected?
An ambulance arrived about two minutes later, and to make a long story short, they noted that G also has asthma. They stabilized her blood pressure, gave her more epinephrine under orders from the ER doctor, and loaded her into the ambulance. They were going to give her an Albuterol treatment for her asthma en-route to the hospital. I was warned not to follow behind the ambulance but to stay back and be aware of traffic conditions. The ambulance was going to run with lights and sirens, and I wasn’t to even think about keeping up with them. When I got to the hospital, the ambulance had been there fifteen minutes. They kept her in the ER for several hours to insure her condition stabilized, and discharged her with orders to get two new EpiPens first thing the next morning.
There are extremely important lessons here for anyone who has or comes into contact with a person who has severe allergies and could go into anaphylactic shock.
The avoidance of allergens is all on you. No one else can or should bear the responsibility of taking all the precautions, because it’s your life that’s at risk. According to restaurant public relations guru John Imbergamo, there are things you should and should not do when dining at a restaurant.
You have to ask every time and double check every time. It means every time you order. If you tell the server when you order your entrees, tell him again when you order desserts. Don’t assume a dish is safe. And if the server isn’t 100 percent positive then ask for the executive chef or general manager to verify what’s in the dish. Make sure that you avoid any dish that can be inadvertently infected because of cross contamination. Restaurants can be expected to take reasonable precautions, but you’re the one who has to be sure. The restaurant is not a hospital and cannot be expected to have sterile kitchens.
You shouldn’t eat at any store that by their nature can cross-contaminate foods. For example, you can’t eat at most ice cream or gelato stores. They have products that contain nuts, and while you may not order that flavor, the serving scoops were at some time probably used to scoop ice cream with nuts in it and not completely sanitized.
Just because a particular dish you had before was safe once doesn’t mean it’s always safe. First, ingredients can change, and second, you may not have reacted the first time but could at another time.
Don’t expect the restaurant to be a hospital. You should carry two EpiPens with you everywhere you go. Sometimes an antihistamine like Benadryl® can help, but you can’t rely on it 100 percent, nor can you rely on it at all once you’ve gone into shock.
Never eat at a buffet. The risk of cross-contamination or cross-contact is very high.
Avoid desserts not prepared at home. The opportunity for unknown ingredients is high. If you are suffering from a lack of sweets, opt for fresh fruit. Or wait until you get home. I always have ice cream in my freezer at home. That’s my 10 p.m. meal most every nite.
Don’t let the server ask a line cook about ingredients. He needs to inform the head cook or chef or manager. Often a restaurant relies on unsophisticated cooks to prepare parts of the meal and they may not be as knowledgeable or understanding as a head cook.
G and I were recently at a local restaurant, and they had the allergy info right on the ticket. Each dish that G ordered was printed on our bill (and the ticket to the kitchen) with the allergy information noted. Tonite I noted that Panera Bread Company uses different tongs for every salad they prepare to avoid cross contamination. I was impressed. Every restaurant should do that.
There is so much to know about allergies, I can’t cover it all in this column. For everything you ever wanted to know about food allergies, go to FAAN (Food Allergy & Anaphylaxis Network) website, www.foodallergy.org. You should become a member of this organization (no fee) and receive their regular mailings and warnings.
You can download from their website a “chef card” that lists your allergies. You carry the card and give a copy to the chef or manager every time you go into a restaurant. Every single time.
The last thing, know how to administer the injection. That means, using a test pen that now comes with the two-pen kit. Practice. Because if you get where you actually need to administer the injection to yourself or to someone you’re with, you may not have the time to read the simple instructions or be able to do it. Like me.
After the incident, I had a list of questions that I needed to know for the next time. Cuz there very well may be a next time. So I called the gurus, the folks at National Jewish Health who deal with these problems day in and day out. Here are the questions I asked and the answers I was given by Dr. David M. Fleischer.
Q: My wife ate a walnut. Instead of spitting it out, she swallowed it. I assume if she had spit it out, she would not have, or perhaps may not have had the reaction.
A: No way to know that she would not have had anaphylaxis if she did not swallow it — she could have been exposed to enough to cause the same reaction — (I) don’t know what her threshold to cause anaphylaxis is.
Q: When a person first realizes he/she has eaten a nut, how long should he wait and under what circumstances she he give himself or be given an epi injection? It seems waiting until he is in shock is not good, especially if the person is by himself. When is it recommended to administer the injection?
A: The earlier epi is administered in anaphylaxis the better.
Q: How many injections, assuming all are .30 mg can you give? Is there a risk of giving too much adrenaline? I remember attending a FAAN meeting for children allergies, and they sed that the .15 mg in a children’s set can often be insufficient and you should carry a twin-pack and may have to give both injections.
A: We recommend that patients keep two auto injectors of epinephrine together in case they need a second injection. Sometimes you need a second dose as the first is not enough or the reaction is getting bad again 10-15 minutes later and an ambulance has not arrived yet.
Q: Is there a point where you shouldn’t give any more, as in even a 3rd shot?
A: I personally have not had to use more than two doses and would say this would be rare to not respond to two doses; I would be concerned that the epinephrine was not administered properly into the thigh and held for 10 seconds or that it was administered too late in the course of anaphylaxis to make a difference.
Q: How does the treatment for a person with asthma change? In the above case, when they found out my wife also had asthma — and normally very low blood pressure, they did administer a nebulizer treatment in the ambulance.
A: If a patient has asthma, it makes them at a higher risk for life-threatening anaphylaxis unfortunately. Therefore it is imperative to give epinephrine early in these patients. You can then give albuterol after you give epinephrine.
Q: If a product such as Benadryl is available, should that be given immediately, and hopefully will prevent the need for the epi injection? I understand that waiting until the person has gone into shock is too late for the Benadryl.
A: If you are talking about anaphylaxis (which I am substituting for your word shock) then Benadryl is always a secondary medication. Benadryl is given for mild symptoms such as a few hives, sneezing, congestion, abdominal pain, vomiting once, mild lip swelling. If you get generalized hives (a sign of a systemic reaction), severe facial swelling, difficulty swallowing/throat tightness, vomiting more than once, any coughing or wheezing (lower respiratory symptoms), multi-organ symptoms, or fainting, dizziness (signs of low blood pressure, epinephrine is always first.
Q: If the person knows they ate an item they are extremely allergic to, can they just go ahead and inject the epinephrine immediately and reduce the risk, or can that cause a separate risk?
A: We have two rules for automatically recommending giving epinephrine: (1) if someone has had a previous anaphylactic reaction to a food and knowingly has ingested that food again, do not wait for symptoms, give epinephrine; (2) if you have asthma and knowingly ingested that food and have respiratory symptoms, give epinephrine. You can then give the secondary medicines such as Benadryl and albuterol afterwards. Also any time you give epinephrine, 911 should be called, and you should be transported to the emergency room for observation as the reaction can return.
Q: Is it fact that once a person has gone into shock from a nut or bee sting or whatever, that any subsequent occurrence will come sooner than the first and likely be more serious?
A: Yes, subsequent reactions can either be just as serious as or worse than the previous one. Note that I always refer people to consult with their own medical professional before they even develop a plan for what to do in the event. It is important to see an allergist and develop an anaphylaxis action plan, always carry epinephrine auto injectors (two preferably) and an antihistamine (preferably in the liquid or chewable/fast melt form, not tablet as we want it to be rapid in onset).
G and I are indebted to my “guru” consultants; first and foremost, Dr. David M. Fleischer at National Jewish for his prompt and thorough answers to all my questions. Then Adam Dormuth, media relations at National Jewish who got me together with Dr. Fleischer quickly so I could go to press timely. And the lady who put me on track in the first place, Nancy Gregory, Media Relations and Associate Editor of FAAN. And last but not least, the delightful and always informative John Imbergamo of the restaurant consulting firm, The Imbergamo Group.
Jay Fox is the dining critic for The Colorado Statesman. He can be reached at: firstname.lastname@example.org.