H1n1

[TysonCook]

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We need ACEP to release a statement to the media about H1N1, I'm getting 35+ patients in a 10hr shift with ~10 being "flu" symptoms...and very few if any qualify for tamiflu.

If you're an ACEP member send off an email, it can't hurt.

Lastly, the ~3 that come in saying they "knew they shouldn't be there but the school required a note" BS is really pissing me off. I'm going to ask the charge RN to place a not saying that if you are there for just a school note you don't need to be seen by the MD.😡

 

[Apollyon]

Lastly, the ~3 that come in saying they "knew they shouldn't be there but the school required a note" BS is really pissing me off. I'm going to ask the charge RN to place a note saying that if you are there for just a school note you don't need to be seen by the MD.😡

Actually, you can bill a level 2 visit for a work/school note only, and your chart can reflect same (like, "Pt is alive. Requests work note." Document V/S, general appearance, breathing, and normal gait).

 

[Stitch]

What she (and most of the media) overlook is that an ED full of well people is like looking for a needle in a big a** haystack. You know there's a sick person in there somewhere but there's an awful lot of time-consuming hay to move out of the way before you find them.
Take care,
Jeff

That's what frightens me.

Another frustration I'm running into is the PCPs who send NOT sick kids to the ED for no reason. Last night one of our private notorious dumpers sent in a 4 month old former 24 week premie who's fresh out of the NICU with chronic lung disease in because the kid sneezed a few times. Seriously! Thought the kid might have swine flu. I told mom (who hadn't wanted to come in) that he probably didn't have swine flu coming in, but was likely to catch it from the waiting room. I have no doubt the flu would kill this kid, and it really galls me to see these very young ones sitting in a waiting room full of sick and semi sick people.

 

[KidDr]

That's what frightens me.

Another frustration I'm running into is the PCPs who send NOT sick kids to the ED for no reason. Last night one of our private notorious dumpers sent in a 4 month old former 24 week premie who's fresh out of the NICU with chronic lung disease in because the kid sneezed a few times. Seriously! Thought the kid might have swine flu. I told mom (who hadn't wanted to come in) that he probably didn't have swine flu coming in, but was likely to catch it from the waiting room. I have no doubt the flu would kill this kid, and it really galls me to see these very young ones sitting in a waiting room full of sick and semi sick people.

completely agree--
sending a kid like that to wait 2+ hours in a waiting room full of H1N1 is a really dumb move.

 

[Katydid]

I feel your pain. I'm seeing between 15 and 20 of these a day now in our "quiet" little community ED. Each one turns into an uphill education session battling the forces of media "education", schools that tell parents to rush their child to the ED for their temperature of 103 and Oprah peddling her vaccine nonsense.

One of my nurses got pissed at me the other day because I'm getting so frustrated with all of these folks. She keeps saying "yeah, the department and waiting room are full and you're the only doc, but so what, they're not sick".

What she (and most of the media) overlook is that an ED full of well people is like looking for a needle in a big a** haystack. You know there's a sick person in there somewhere but there's an awful lot of time-consuming hay to move out of the way before you find them.

I'd like to think there's a light at the end of the H1N1 tunnel, but I suspect it's just the oncoming seasonal flu train.

Take care,
Jeff

It's people like this who are the reason that we all got seasonal flu shots, and I'm continually checking in with the county health department to find out when H1N1 vaccine is available.

Do they ever stop to think that just maybe if they'd gotten vaccinated, just gotten a little stick, that they might not be having to worry so much about seasonal flu and H1N1? Noooooo, they've all heard from various "sources" (read that as "people peddling anti-vax nonsense") that H1N1 vax is not safe.

I would rather get a little stick, or something put up my nose, than get either seasonal flu or H1N1.

 

[PsyDGrrrl]

What do you guys think about the H1N1 vaccine? It's not required for employees at my job but strongly, strongly recommended. I'm a little wary of getting it, but I *do* come in contact with high risk patients (inmates straight out of county jails...who knows what they've been exposed to). I personally have never had a problem with getting regular flu shots, but I'm a little concerned with how quickly the H1N1 vaccine was rushed out and how we're requiring all of our patients to get it.

 

[Stitch]

What do you guys think about the H1N1 vaccine? It's not required for employees at my job but strongly, strongly recommended. I'm a little wary of getting it, but I *do* come in contact with high risk patients (inmates straight out of county jails...who knows what they've been exposed to). I personally have never had a problem with getting regular flu shots, but I'm a little concerned with how quickly the H1N1 vaccine was rushed out and how we're requiring all of our patients to get it.

I understand where this worry comes from, but there's TONS of information out there dealing with the 'it came out too fast and wasn't tested' issue. Basically H1N1 is a flu shot like any other flu shot. It was developed the same way. The only difference is that it contains H1N1 instead of various other strains of flu. The season flu shot is reconstituted every year to include the most likely circulating strains. Had H1N1 shown up a little earlier, it would have been included in this years seasonal flu shot rather than adding it on as a separate shot.

As it is however, you may not be able to get the shot depending on where you are and how available it is.

 

[KidDr]

I understand where this worry comes from, but there's TONS of information out there dealing with the 'it came out too fast and wasn't tested' issue. Basically H1N1 is a flu shot like any other flu shot. It was developed the same way. The only difference is that it contains H1N1 instead of various other strains of flu. The season flu shot is reconstituted every year to include the most likely circulating strains. Had H1N1 shown up a little earlier, it would have been included in this years seasonal flu shot rather than adding it on as a separate shot.

As it is however, you may not be able to get the shot depending on where you are and how available it is.

And I would add this obvious point too---unlike the seasonal flu vaccine, for which there is always a possibility of a mismatch between which strains are included in the vaccine, and the strains that actually end up circulating during flu season---the H1N1 vaccine is a sure thing. It only contains H1N1 antigen and (to state the obvious) that's the only strain circulating right now. It's actually a perfect vaccine in that regard (strain matching, not efficacy), which is more than you can usually say about the seasonal flu vaccine (not saying the seasonal vaccine is bad...just drawing a comparison). I wish the media would play up this point instead of giving screen time to people spewing anti-vaccine nonsense.

 

[Stitch]

What are you guys telling people who come in without high risk histories but with flu like illnesses demanding or really wanting Tamiflu? How often are you handing it out? I've been pretty good about sticking to the guidelines and talking those in low risk groups out of it, but was curious what you all did. Especially since there's not an unlimited stash of the stuff.

The CDC states that Tamiflu may reduce morbidity/mortality, but I can't really confirm this statement with real data. What arguments do you use?

 

[southerndoc]

The CDC states that Tamiflu may reduce morbidity/mortality, but I can't really confirm this statement with real data. What arguments do you use?

It costs $90. If they don't have insurance, that usually makes them demand it a little less.

 

[BADMD]

the H1N1 vaccine is a sure thing. It only contains H1N1 antigen.

This is becoming a pet peeve of mine and so please understand that it is not directed at you, but at all physicians. I've been ignoring the urge, but apparently today it popped out.

As much as the media is calling this H1N1 flu, we in the health care profession need to be a bit more precise. The standard flu vaccine does contain an H1N1 stain, just not the novel/Mexican/Swine variant. An H1N1 is a very common type of flu. We should probably add modifiers if we are going to refer to this as H1N1.

Back to your regularly scheduled thread.

 

[southerndoc]

We should probably add modifiers if we are going to refer to this as H1N1.

We are supposed to refer to it as novel H1N1.

 

[DrMom]

It costs $90. If they don't have insurance, that usually makes them demand it a little less.

Add to it that it won't make them feel better now, all it's likely to do is cut the last 12-24 hours off the end of a 7-10 day illness.

 

[Stitch]

Add to it that it won't make them feel better now, all it's likely to do is cut the last 12-24 hours off the end of a 7-10 day illness.

I totally agree and this is the tact that I take, however the CDC website states specifically that "influenza antiviral medications can reduce the severity and duration of influenza illness and can reduce the risk of influenza-related complications, including severe illness and death."

Even our ID department agrees there's not adequate data to support this statement, yet there it remains, and sends the message to patients that Tamiflu will save them. 😡

 

[dmitrinyr]

Add to it that it won't make them feel better now, all it's likely to do is cut the last 12-24 hours off the end of a 7-10 day illness.

Don't forget to tell them about occasional (and in my experience frequent) side-effects of tamiflu, especially abdominal symptoms, n/v... Last year when I was an IM intern, many of our residents got tamiflu for direct exposure to H1N1 pts. Many docs stopped taking tamiflu after a few days (myself included) after the side-effects were worst than the possible symptoms of H1N1. No one came close to finishing the 10 days regimen.

 

[med2UCC]

The local school district requires a doctors note to miss school, so when they can't get into the PCP, or don't have a PCP, they come to the ED. I had 4 patients last night who specifically required a doctors note to stay home, in addition to the "flu crowd".

.

I've started asking people right off the bat if they need a note and if that is the main reason why they've come in. If the answer is yes I write the note right then and there, do a quick H&P and send them on their way if nothing more seems warranted.
Fortunately, our district has now set up flu clinics and our triage staff stop talking to them as soon as flu-like symptoms rear their ugly head and redirect them. Hurray! Ocasionally they get sent back, but mostly this sorts them out.
Sadly this is just going to get crazier as the season progresses. Good luck everyone,
M

 

[med2UCC]

Our hospital is now sending anyone admitted with a community acquired pneumonia to an H1N1 specific ward, whether they have it or not. The end result of this is that a lovely woman I admitted on Friday with a probable exacerbation of her CHF due to running out of Lasix on Sunday (and not wanting to bother her doctor when he was so busy curing swine flu afflicted patients) is now on said ward because her chest x-ray was equivocal. She probably didn't have H1N1 when she went in but will have it soon... Oh dear! Oh damn! Oh buggery!
Oh well.
Cheers,
M

 

[med2UCC]

Is your institution requiring them? Ours made a big stink about it. At first they were saying they wouldn't allow anyone to work who wasn't vaccinated, but now state that if you aren't documented as being vaccinated, then you have to wear gloves, gown and mask for your whole shift. This approach seems to be working.

Nonvaccinators piss me off.

Oh dear, 3 posts in a row. In our institution we are all being strongly encouraged to be vaccinated. They are tagging our ID's as we get jabbed and anyone who doesn't have the little red dot is being asked pointedly if they would like their jab now. The nursing crew going the jabs comes through our unit once a day, at a different time each day, so it's kind of hard to avoid them. They do this every year, BTW, with the seasonal flu vaccine, and they are always this zealous.
On a lighter note, we think they should have gotten little pig stickers for our ID badges. Might have encouraged compliance. Cheers,
M

 

[Jeff698]

As an update to my initial whine about getting my ass kicked by flu, things are finally starting to die down in my neck of the woods.

Out of an average of 36 or so patients I'm seeing a day, now only about 2-3 having anything I'd even closely relate to flu.

I can see a light at the end of the tunnel. Unfortunately, it's probably only the seasonal flu train headed my way.

But for now, I'm savoring the feel. Savoring, baby, savoring!

Here's hoping Halloween scared the H1N1 out of everybody's departments.

Take care,
Jeff

 

[DrMom]

We've been dropping in flu-like visits here over the past 7-10 days. My last 3 shifts I don't know that I had more than 3-5 total of those patients. Huge change from just last week.

 

[EM2BE]

Dropped where I am now too.

 

[GeneralVeers]

When patients come in complaining of "fever, cough, body aches, and chills" I ask them: "Do you have any idea what could be going on with you?"

The typical answer I get is a blank stare and a shake of the head. Do the majority of the public really not know what flu symptoms are, and that they don't need to be in the ER?

 

[Jeff698]

When patients come in complaining of "fever, cough, body aches, and chills" I ask them: "Do you have any idea what could be going on with you?"

I ask almost the exact same thing as I try to get a feel for what their expectations are. I suspect most think it is the flu and want either a test or Tamiflu but also know that most people don't need to be in the ED so they're a bit coy about the whole thing.

Take care,
Jeff

 

[Stitch]

Wow, so it looks like my sister was just transferred to the ICU with presumed H1N1 and pneumonia. Ended up going to a smaller community ED near my parents place with shortness of breath, where they noted bilateral pneumonia and hypoxia. I don't know the whole story, but my dad says they 'were afraid to intubate her' in the ED so they sent her by life flight to the nearby university hospital where she went straight to the unit.

She wasn't vaccinated but was young and had no other medical problems. 🙁

 

[dmitrinyr]

Wow, so it looks like my sister was just transferred to the ICU with presumed H1N1 and pneumonia. Ended up going to a smaller community ED near my parents place with shortness of breath, where they noted bilateral pneumonia and hypoxia. I don't know the whole story, but my dad says they 'were afraid to intubate her' in the ED so they sent her by life flight to the nearby university hospital where she went straight to the unit.

She wasn't vaccinated but was young and had no other medical problems. 🙁

Man, that really is unfortunate. We'll pray for her to get better and hopefully leave the hospital soon.

 

[DrMom]

Wow, so it looks like my sister was just transferred to the ICU with presumed H1N1 and pneumonia. Ended up going to a smaller community ED near my parents place with shortness of breath, where they noted bilateral pneumonia and hypoxia. I don't know the whole story, but my dad says they 'were afraid to intubate her' in the ED so they sent her by life flight to the nearby university hospital where she went straight to the unit.

She wasn't vaccinated but was young and had no other medical problems. 🙁

I'm sorry to hear about your sister. Post flu staph pneumonia can be scary. I hope she gets better soon.

 

[EM2BE]

Wow, so it looks like my sister was just transferred to the ICU with presumed H1N1 and pneumonia. Ended up going to a smaller community ED near my parents place with shortness of breath, where they noted bilateral pneumonia and hypoxia. I don't know the whole story, but my dad says they 'were afraid to intubate her' in the ED so they sent her by life flight to the nearby university hospital where she went straight to the unit.

She wasn't vaccinated but was young and had no other medical problems. 🙁

Wow. Sorry to hear. Hope she gets better soon.

 

[Jeff698]

Stitch,

I, too, am sorry to hear about your sister. Hopefully, she'll do well.

Her case does bring up an interesting question for me, though. We've all heard of people who get very ill from H1N1. We've all seen, give or take, a sh*tload of well patients with H1N1.

Has anyone seen a well looking patient without co-morbidities and normal vital signs who was later return very ill?

So far, the only patients I've seen with H1N1 who were sick actually looked sick (our EM definition of sick, mind you). Obviously, if there are patients out there who are much sicker than they look, we've got a problem.

Take care,
Jeff

 

[Stitch]

Thank you everyone, for the well wishes. She's stable and her other organ systems seem to be functioning so far. Hopefully they can wean her over the next few days.

Has anyone seen a well looking patient without co-morbidities and normal vital signs who was later return very ill?

So far, the only patients I've seen with H1N1 who were sick actually looked sick (our EM definition of sick, mind you). Obviously, if there are patients out there who are much sicker than they look, we've got a problem.

Take care,
Jeff

I'm with you here. Most of the people I've seen look sick, and it's not been subtle. But we're bound to run into these types of cases as the season progresses, and identifying them will be difficult, if even possible. Are these types of cases going to be turned on us for not giving them Tamiflu when they present early looking well and aren't high risk?

 

[med2UCC]

Hey, sorry to hear about your sister. I hope she gets well soon.

In response to the question about patients with no comorbidities who look well, we had one over the weekend. She was 20 and her vitals were good except for a mild tachycardia. Her lungs sounded clear, but I send her for a chest film anyway as she was tachy. Huge right lower lobe pneumonia on the x-ray. She only came in because her mother was worried. Now mind you, she would probably have fought the pneumonia off on her own and she didn't get admitted. We sent her home on antibiotics; I have been watching for her on our EMR system and so far she hasn't come back in. I'm assuming she's home getting better.

So far this is the only sneaky one though. I've been a little more paranoid about imaging since we really started getting slammed with this and so far the ones who look sick are the ones who are sick.

Hang in there lads,
M

 

[DrMom]

Has anyone seen a well looking patient without co-morbidities and normal vital signs who was later return very ill?

So far, the only patients I've seen with H1N1 who were sick actually looked sick (our EM definition of sick, mind you). Obviously, if there are patients out there who are much sicker than they look, we've got a problem.

Take care,
Jeff

I've had a 21 year old healthy guy come in with pretty routine flu-like symptoms return 36 hrs later with bilateral MRSA pneumonia. He was clearly very sick on the 2nd visit.

 

[KidDr]

Thank you everyone, for the well wishes. She's stable and her other organ systems seem to be functioning so far. Hopefully they can wean her over the next few days.

that's great to hear that she's doing okay so far. hope she continues to feel better!