Letter to the Editor
Congratulations to James Roberts, MD, on covering a critically important entity for anyone working in an emergency department. (“A Silent Epidemic: ACE Inhibitor Angioedema,” EMN 2012;34:1; http://bit.ly/MS3z2l.) Since starting work in an ED in 1977, I would say that ACE inhibitor angioedema has definitely been one of the most anxiety-producing problems I have seen. Though I have been fortunate not to have any deaths, we recently had a case in a local community hospital that, fortunately, did not find the emergency physician liable at trial. That, of course, does not mean that it didn't take three years out of the physician's life going through the legal ordeal, and it undoubtedly changed him forever.
Several points in the article were illuminating. No drugs currently on the market treat this problem, and we've gotten into the habit of using the nasopharyngeal scope ourselves or having our ENT consultants scope them for evidence of airway involvement. I don't know that a black box would do anything more than end up causing another valuable dug class to disappear.
There is no question that ENT is close at hand 24/7 to lend expertise with these patients when working in a major teaching metropolitan hospital that sees 82,000 patients a year, but try calling for ENT consultation in a rural hospital or even a 15,000-patient-a-year community hospital and see what kind of response you get. You are basically on your own with a potential airway catastrophe hoping to God if all hell breaks loose that you are able to get an airway into the patient. After all, no drugs currently treat this problem. Some expert witness willing to make a few thousand dollars will say in court, “Maintaining an airway is fundamental training in emergency medicine, and of course Dr. X is responsible for the death or disability suffered by this patient.”
The physician actually did make a significant “error” in these cases: he picked up the chart! What will happen when, because of the insane expectations of society coupled with the equally insane tort laws, no one is willing to pick up the chart? In an era where an emergency physician is legally liable if he does not have the combined skills of an anesthesiologist, ENT specialist, cardiologist, neonatologist, and critical care specialist, the question of who will pick up the chart becomes a very pertinent question. There has to be a significant “public” effort for tort reform to protect providers in an ED who have little if any warning of what will be coming through the door. To expect politicians (i.e., lawyers) to kill the goose that laid the golden egg will not happen, as shown by the lack of tort reform in the present debate of the Affordable Care Act.
I don't know what the black Box would do to ACE inhibitors either, but unless there is tort reform to release the provider, who has made every effort to secure an airway, from liability for a failed airway in ACE inhibitor angioedema, these drugs should disappear.
Stephen Lund, MD
Overland Park, KS