Angioedema

It started innocently enough. A slight feeling of fullness in the right side of my upper lip. There was no tingling, burning, or pain so I didn't think much of it. It was about 1600 and I was at work with four more hours on the clock to go. The patients were coming in steadily and they kept me somewhat distracted from what was happening to me. At about 1900 we had a lull in patients and the other nurse practitioner gasp a little and asked me what was up with my lip.

I felt my lips and could tell the right side of my lip and face was beginning to swell even more. I had a suspicion as to what the problem was and discussed it with my partner. She agreed and ordered decadron 5 mg orally. I called my boss and told her I needed to leave work early as I had an urgent medical condition developing.

I filled the prescription of decadron and took 2.5 mg before leaving for home. By the time I arrived home the entire right side of my face was swollen and I could feel it working its way down and back to my throat. Damn, I thought, this can't be happening to me. I took the other half of the 5 mg of decadron and 50 mg of benadryl.

I sat in the dark waiting for the wife to get home and then decide how to proceed. Tick, tick, tick, seemed to take forever for her to get home and I continued to worsen. I could feel my throat tightening and it was becoming difficult to swallow on the right side. Though the swelling does not look that bad from the outside, inside my mouth my cheeks were swelling far more than the outside.

She arrived shortly and changed into her evening wear. She then began to question me and examined me as a nurse practitioner spouse is want to do. She asked if I wanted to go to the hospital. At first I said no, then thought about it for about 30 seconds. Well yes, take me to the ER. Those were shocking words to me. I am the last person who would ever go to the ER for anything. I once lacerated my finger bad enough to need stitches. I set up a suture station at the kitchen table and taught my wife how to suture on the spot. No lidocaine necessary. Another time I broke my 5^th metatarsal and dislocated it. It was sticking straight up almost poking through the skin. I simply reached down with my thumb and pushed it back in place without any lidocaine. Yes it hurt, but there was no way I was going to go to the ER and have someone else do it. I hate going to the ER but here I was admitting defeat and having my wife drive me to the ER. On the way the swelling continued to worsen.

She dropped me off at the ER entrance and I went inside and stood by the triage RN and waited for him to finish with his current patient. It seemed like he was taking forever when it was probably only 45 seconds in real time. As soon as he finished and before he could call for another patient I interrupted him. Yes he asked? I pointed at my face and said one word, angioedema.

Stand right there and don't go anywhere he responded. He grabbed the triage tech and told her to take my vitals and information while he finished with his next patient. As soon as she was finished with taking my vitals and other medical information I was back with the triage RN.

He was very thorough in his assessment and questioning and assured us I was a top priority to be taken back and treated. He finished with his questions and we retired to wait in the lobby until a bed was available. In the mean time a nurse popped in repeatedly to make sure I was still ok. I had a tight feeling in my throat and a little difficulty swallowing but was still able to breath without difficulty.

It took about 45 minutes for them to take me to a room. Even though I knew I had a life threatening problem I was not angry or demanding about the wait. I would have called myself stable and felt the triage nurse assessed the problem appropriately. Emergency rooms have their beds assigned to different tasks. Some of the beds are for broken bones (ortho beds) some areas are for non-life threatening medical conditions like abdominal pain, urinary tract infections and such. Then there is usually a small number of beds for life threatening medical conditions and trauma. I was in need of one of those small number of beds. I knew they would have to do the ER shuffle to make room for me and from what I saw that was exactly what they were doing. I was brought back to a room and told to take off all my cloths except my underwear. I have done the same routine with tens of thousands of patients when I worked the ER so I did not argue, I stripped down as I was instructed. I knew that if I went south the ER crew did not want to have to be distracted to take the time to cut my cloths off instead of intubating and bagging.

And there I lay on the bed waiting. And waiting. An hour went by. The nurses kept checking in on me, taking vitals and assessing my condition. The swelling seemed to be stalled and my tight throat was not getting worse. I don't want to die like this, I thought. I didn't hear about it until the next afternoon but I was told the ER doctor went ballistic on the nurses when he picked up the chart and read "angioedema" as the chief complaint 1 ½ hours after the chart was placed in the chart rack. By this time it was about 0030.

The doctor introduced himself and did a thorough medical evaluation. I knew exactly what he was going to say. He asked me about the decadron. I told him yes, I was a NP and thought I was having an episode of angioedema. He actually said I had probably done the right thing and that I may have prevented more severe symptoms by my earlier actions. But from everything I have ever read about angioedema I didn't think so, but I said nothing.

The doctor left and the nurse soon appeared and explained that she would need to start an IV. I expected it along with the steroids and antihistamines to follow. She prepped a vein and blew right through the first try. I told her that was ok nobody bats 1000. She got the IV on the second try and secured it with less tape than I thought would keep it in place. I added much more tape later, and I was glad I did.

She pushed the pepcid, solumedrol, and benadryl. It took about 2 minutes for the benadryl to hit me. I am very sensitive to benadryl. I have been known to hallucinate on as little as 50 mg orally and I had just had 50 mg IV. I told her before she started the IV I needed to pee. She said I could do so after she pushed the drugs. By the time she finished cleaning up all the wrappers and trash my head was lolled back and my eyes were a-glaze. She asked me if I wanted to walk to the bathroom. I was not going to be macho, I told her no way I was too wobbly. There is a lesson to be learned here. I could have played the macho man, walked half way to the bathroom and fallen down and broken something but I didn't think the nurse or my body would appreciate that. Yes it can be embarrassing peeing into a urinal but its better than breaking open your head or breaking a hip trying to be macho. I asked my wife if she would help me with a urinal and she agreed. One was produced and the nurse left me to my business.

My wife let the bedrail down and I scooted to the edge of the gurney thankful to be able to take some pressure off my sore bottom. Those ER gurneys are anything but comfortable. I wheeled around and used the gurney to steady myself and pull up the gown and pull down my underwear. Then I learned something. Urinals are difficult to use. I had marveled all these years why so many men have trouble using the thing and I found out for myself. I put the urinal to my dick and realized I had to bend my dick 90 degrees to get it into position to pee. Hmm, I never realized that before. I urinated as best I could with a kinked urethra and tried to finish up. As I removed the urinal and unkinked my dick a shot of urine spilled out on the floor. Scowls from the wife as it landed just at her feet almost landing on her. She put me back on the gurney and cleaned up the urine on the floor with the antiseptic that was on the counter. I tucked this new piece of information away and would use it later for a more successful trial with the next urinal.

And now we had to play the waiting game. An hour went by, then another 30 minutes. The nurses constantly checking on me making sure I was comfortable, safe, still able to breath. Then the ER doctor came back to re-examine me. He took one look at me and made a straightforward statement. We need to admit you to the ICU. I just nodded my head in agreement and eked out a weak who is the Hospitalist? He told me his name and that he was next door admitting another patient and would be with me shortly. Another hour and a half went by but it really didn't matter as it made no difference to me if I was in the ICU or the critical care area of the ER. The benadryl did its number on me and I began to have uncontrollable twitching. Well at least this time I was not hallucinating. By the time the Hospitalist arrived both my upper and lower lips and right lower cheek were severely swollen. He completed his exam and reaffirmed that I needed an ICU bed and left to confirm the admission. At this point I asked my wife if she wanted to go home as we had both been up almost 23 hours. She said no at first then as time went by I asked her again and she decided she had had enough for one night. She kissed me goodnight and left telling the ER nurse to take good care of her Homer while she was gone. The ER nurse responded "DoH." You can take the ER nurse out of the ER, but you can't take the ER humor out of the ER nurse.

They transported me to one of the ICU's and settled me in a bed in a corner room. Once in bed I got the usual bundle of wires attached to various parts of my body. I tried to lay on my side to get some rest but everytime I rolled to either side I would set off the alarm on the cardiac monitor. I was wound up from the drugs and at this point I was just too tired to sleep. When the nurse came to check on me shortly I pointed and asked her which cameras were working? She said none of them. I took note of that but one of them had a little green led lit so I suspected it was the working camera.

My right cheek began to swell. It looked at one point as if someone had cut a baseball in half and glued it to my cheek and painted it flesh tones. The pressure in my lips and cheeks was tremendous to the point of stretching the nerve endings past the point of feeling. I was worried but the throat pressure I had felt the night before was still gone and my breathing seemed unimpeded.

Time went by and I was beginning to become increasingly thirsty. It was now 0600 and I had not had anything to drink since the small sip of water I had had at 1900 the night before. The last food I had had was at 1300 the previous day. At 0700 I asked for a glass of water. The nurse examined me, my lips in a rictus and horribly swollen now. She brought in a cup with some ice chips and a spoon. She figured that I would have been unable to drink from a straw or cup and that all I would end up doing is spilling ice water all over myself. Later, after a little of the swelling went down I tried to drink from a straw. She had been correct, there was no way I could have done anything other than make a huge mess had I had a cup of water.

At 0730 the day nurse arrived and introduced herself. She had two students in tow and asked if they could help care for me. Sure I said, it would be a good experience for them as this condition is not seen very often. I spoke with the students and explained that I had gotten little rest in the past 24 hours but to come back later and I would give them a tool to help them remember the cranial nerves. They laughed and I told them I was faculty at their schools and was not kidding about the tool I could teach them.  

Between 0700 and 0730 I actually slept a little. This was after being up 25 hours. Around 0800 the nurse brought me breakfast. She had ordered a single pancake with juice and a skim milk. She knew that because of the swelling I would only succeed in chewing my cheeks to bits if I really had to chew a hard food. The pancake could be massaged by my tongue and washed down fairly easily. I normally detest pancakes but that one seemed the best I had ever had.

Whether through time or drugs the swelling was finally starting to go down. Hour by hour it improved and the drugs kept coming. Large doses of steroids and antihistamines.

After eating I had to urinate again. I scooted to the side of the bed moving the tangle of wires with me, not an easy feat. I slid over the edge of the bed and used it to steady myself. This time instead of using the urinal as intended I turned it around so the handle was between my legs instead of pointing away from me. Urination went off with no problems and I did not have to bend my dick into that awkward 90 degree angle. I had discovered that male urinals when used standing up have the handle on backwards.

As I crawled and shimmied back into bed I felt something akin to a dog tethered to a pole. I could sit on one side of the bed only and movement in the bed was limited because of the harness of wires attached to many points on my body. It was also very uncomfortable for me to urinate with someone watching me from a closed circuit camera. All in all though I would prefer to be in a room that is monitored as it gives an extra little bit of comfort knowing they are keeping a close eye on you.

The swelling continued to subside and by lunch time I was able to take in some soup. To keep from being bored to tears I questioned the students about the drugs the nurse was giving me. I quizzed them on class, route of administration, pharmacodynamics and pharmacokinetics. The ICU nurse seemed to get a kick out of her patient torturing her students about the drugs I was getting.

About 1500 the ICU nurse called the Hospitalist and reported the majority of my facial swelling was resolved and he may want to come and either transfer me or discharge me home.  He was there within 30 minutes and re-examined me. He asked me if I wanted to go home and I responded with a firm yes. Discharge instructions and scripts were written and I was free of the tether once again.

Looking back on the discharge it might have been better if they had kept me another 24 hours because I had not slept for 36 hours by the time we got home. I don't remember anything past about 1930 hours. The large doses of steroids caught up with me and my wife tells me I babbled incoherently throughout the night. She being a seasoned ER Nurse and Nurse Practitioner was able to handle me without having to call the paramedics to haul me back to the hospital. Its 2 days later now and I'm still on high dose steroids. Put a container of cream in my hands and in short order you will have butter I'm shaking so much. I know this too will pass and things will get back to normal. One thing I know, I will never take an ACE or ARB again the rest of my life.

*Update- ACE= Angiotensin Converting Enzyme Inhibitor, ARB= Angiotensin Receptor Blocker. Two classes of blood pressure medication that can cause angioedema. In my case Lisinopril a medication in the ACE class.

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