Teamwork saves girl whose peanut allergy led to anaphylaxis, cardiac arrest

It was a Friday night just a few days before Christmas, and the care team at the MUSC Shawn Jenkins Children’s Hospital was ready for holiday-related ailments on top of the usual illnesses and injuries. But it was about to be tested by something else: a teenage girl’s allergic reaction to peanuts – a reaction so severe that it almost killed her and required extraordinary measures to save her life.

The girl was Charlotte Whitley, a high school junior who lives in Mount Pleasant, South Carolina. Charlotte, 16, was home with two of her three brothers when they ordered dinner from a local restaurant.“I got the same thing I’ve had before,” Charlotte said. 

But this time, her family believes, there was a new ingredient: peanut butter. It was obvious right away that something was wrong. “I ate the food and then my mouth had an extreme reaction. It just was, like, really painful. I have other allergies, and when I eat those things, usually my mouth feels fuzzy. Or it'll just hurt. But this was like an explosion of hurt. And so I was like, ‘This is a really bad one.’ So I spit out what I could and called my mom.”

 

Her mom, Guang Ming “GM” Whitley, came home and gave Charlotte a shot of epinephrine from her EpiPen. Epinephrine is also called adrenaline. It can treat allergic reactions.

“Then we drove to the ER,” Charlotte said. 

She and her mother were wary because Charlotte had had a strong reaction to peanuts in the past called anaphylaxis. It can be life-threatening, causing breathing trouble, facial swelling, shock and unconsciousness. So her family wanted to get her to a hospital where doctors could keep an eye on her in case she took a turn for the worse.

At the hospital

Christopher Stem, M.D., was one of the emergency medicine specialists working that evening.“We take every case of possible anaphylaxis seriously, so I evaluated Charlotte right away. She was able to walk into the hospital and her breathing sounded relatively good, with mild wheezing. But given that she still had symptoms despite using her EpiPen at home, we also placed two IVs in case additional medications were needed if her symptoms worsened.”

 

To address that wheezing, the care team gave her another EpiPen and a breathing treatment. Normally, that would be more than enough to fight an allergic reaction.

But this situation was anything but normal. One of the nurses on duty that night, Sarah Hudson, was asked by her charge nurse to keep an eye on Charlotte. “I went in there and saw she looked pretty uncomfortable, pretty distressed,” Hudson said.

Knowing Charlotte’s history of anaphylaxis and seeing that she wasn’t responding quickly to the initial treatments, the care team put Charlotte on an epinephrine drip. And Stem and fellow ER doctor Asha Kumar, M.D., worked together to come up with a plan.

“I went to talk with our PICU colleagues because that would be the next step on where she'd have to go while on an epinephrine drip with continuous breathing treatments,” Stem said, referring to the Pediatric Intensive Care Unit. 

Meanwhile, Kumar had a conversation of her own that showed how serious the situation was becoming. Charlotte’s condition was deteriorating rapidly. “One of the nurses came up to me and said, ‘This girl just dropped her blood pressure acutely. I'm really worried.’ So I ran back there, and she was having acute difficulty breathing. It was very dramatic,” Kumar said.

The night went from a watch-and-wait situation for Charlotte to a full-blown crisis. 

Crisis care

The ER doctors found their patient flailing on her bed. “It looked like an anxiety attack, but in reality, she was in pre-arrest,” Kumar said. The petite teenager’s breathing and heart stopped.

 

Her terrified mother waited just outside the room. “They brought her back [to life]. And I learned later she suffered a second cardiac arrest,” Whitley said.

Intensive care specialist Josh Arenth, M.D., alerted by Stem, came from the PICU to the Emergency Department. “When I got down there, they were doing CPR. We continued all the interventions that you can do for someone who's having an acute anaphylactic shock and who's had an arrest. And so it became pretty clear, pretty quickly, that none of those things were going to work fast enough to keep her alive. The only other thing you can really do is put someone on a heart-lung bypass machine called ECMO.”

Turning to ECMO

ECMO, extracorporeal membrane oxygenation, helps with heart and lung function in critically ill patients such as Charlotte. Kumar put in a call to Laura Hollinger, M.D., medical director of the pediatric ECMO program. 

 

“So I came running in and called the ECMO team to get a pump ready for us,” Hollinger said. “And then we were talking really quickly about best place to cannulate.” Cannulating means connecting Charlotte to the machine with a tube.

“We typically do it either in the operating room or the ICU. We've never done it in the Emergency Department, which doesn't mean we can't, but it's more difficult because you're bringing in a lot of heavy equipment into the space. So we elected to get her to the ICU and then cannulate her there.”

Charlotte now had a machine keeping her alive, doing the work her lungs could no longer do. Hollinger explained why that was needed. “Her degree of inflammation and bronchial reactivity had caused her lungs to basically expand without being able to contract. So she was filling up with CO2 but not able to exhale it.”

 

The decision – and ability – to use ECMO for a case such as Charlotte’s was rare, Hollinger said. “From an ECMO perspective, it is extremely rare for a patient with a peanut allergy like hers to escalate so far that people are talking about ECMO. There are fewer than five cases ever reported in our big international registries. That’s another part of Charlotte's story that I think is so unique. Had she gone to any other place other than MUSC Children’s, she would've died.”

Arenth agreed. “I've never seen anaphylaxis as bad,” he said. “There was a team of 30-something people at the point when we were trying to get her on ECMO up in the ICU. Then we were up all night with her trying to keep her body going.”

Charlotte responds

The first thing Charlotte remembers after her cardiac arrests was being on ECMO as doctors suctioned mucus out of her chest. “I couldn't move and I couldn't talk and I couldn't see, but I could hear everything,” she said.

Everything – including family members who stayed with her around the clock and talked to her, hoping she could hear them. Whitley said a turning point came with the arrival of Charlotte’s boyfriend, who drove to Charleston from Florida to be with her in the hospital. 

“When he came into the room, she was on a paralytic and had electrodes all over her. Her scalp and everything. And he said hello to her. Her heart rate went up, and her blood pressure went up. And for us, that was the first glimmer of hope that she could hear what was going on,” Charlotte’s mother said.

 

She needed that glimmer of hope. The Whitley family was worried about possible damage to Charlotte’s brain. “They were telling us she was without oxygen for at least five minutes. So you can Google that and see what that can do. So we were really worried,” Whitley said.

Arenth, the intensive care doctor, was worried too. “I was not sure how that was going to go for her. And I remember telling her mom, ‘I'm very concerned that if she does survive, how much injury her brain suffered.’”

But another glimmer emerged as the paralytic wore off. Charlotte began communicating with her family by finger spelling in sign language. She couldn’t talk because she had a breathing tube in her mouth, but she could spell with her hands. It became clear pretty quickly that Charlotte’s brain was just fine – and the rest of her was healing, too. “It was like every 24 hours, we had good news,” her mother said. 

“So in the first 24 hours, they were able to stabilize her blood pressure. They gave her some plasma. And then that stabilized her blood pressure. And then 24 hours after that, they removed the ECMO. And then, I think, 24 hours after that, they were able to remove the ventilator. And then they were able to remove the feeding tube.”

Charlotte was still weak and would need months to recover. But she was able to go home on Christmas Eve, five days after she walked into the hospital after the accidental peanut ingestion. “She’s our miracle child – our Christmas miracle child,” Whitley said.

Charlotte did her schoolwork at home in the weeks that followed and went to physical therapy. She and her family have also been looking at how to navigate her future. “This is definitely changing my life forever,” Charlotte said.

She’s getting a peanut-detection dog that will go everywhere with her. And she also hopes that sharing her story will make more people aware of how serious a peanut allergy can be. “I just say respect people. Take them at their word if they say they need something for their health,” Charlotte said.

Her doctors are also looking back at what happened on that unforgettable Friday night and working on a case study for a medical journal to share their experience. Hollinger, the pediatric surgeon who runs the ECMO program, said she’s grateful to have been a part of Charlotte’s care at the MUSC Shawn Jenkins Children’s Hospital. 

“Charlotte’s case really highlights that this is exactly what a top-tier children's hospital is for – these rare cases that require all the pediatric subspecialists coming together to save a life. Her fantastic outcome is what we all strive for every day.” 

For a closer look at allergic reactions, including when to treat one at home and when to get to the hospital ASAP, read this companion story.