Xofluza vs. Tamiflu

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Some of our nurses can't even pretend to ask the patients all those questions fast enough on my low acuity patients. Let's not give them something else to pretend to do.
deuist said:
I like the idea of offering all non-critical patients flu vaccines in the ED. The request could be automatic from the nurse just like "Do you feel safe at home?" The order could also reflexive so that the doctor does not have to get involved. The universal vaccination against influenza from the ED makes a whole lot better sense than when New York made every physician offer HIV testing.
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thegenius said:
I’m really curious about this steadfast position you have about “amazing” tamiflu (the word you used and you wrote above.)
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I think I have been pretty clear about my position and provided links. But to review:

If you have a household contact with flu, you have 40% odds of getting flu. That's any random household contact, but obviously your odds of getting flu are going to go up with your degree of exposure.

If you take Tamiflu as prophylaxis when you have a household contact you don't get flu. 80% odds you don't get it at all, and most of the remaining 20% will have 3-4 days of mild symptoms.

So if your toddler has the flu and you take tamiflu you go from being nearly certain that you are going to spend a week flat on your ass gasping for air to a 20% chance that you are going to have the symptoms of a mild cold. That's pretty amazing.

Once you have symptoms? Not amazing. I think the benefits outweigh the risks, and I therefore prescribe it, but not amazing.
 
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RustedFox said:
Nothing about "I need a flu shot" is emergent.
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Flu vaccination also doesn't have anything to do with inpatient medicine, but pretty much every inpatient service offers it. Also, be honest, you already do lots of non-emergent things. When you see a kid with an ear infection or a bad candida diaper rash you could easily say 'not an emergency' and make the PCM prescribe the amoxicillin/nystatin the next day, but you don't because that would be bad medicine. You take care of it then because its easy and makes someone's life a little better and there is no good reason to put it off. Of course if the non emergent medicine would significantly eat into your time, for example trying to improve a diabetic's glucose control, then you punt to the PCM, but otherwise you just deal with it.

The flu vaccine is a form of preventative medicine that requires you to know next to nothing about your patient's history and requires no follow up. If you already give vaccines (and every ER has at least the tetanus vaccine) it doesn't require any additional training for you staff and requires no additional equipment. It adds less than 30 seconds to your appointments. It can give you the satisfaction of having done a useful thing during what otherwise would be completely useless visits. Why not give it?
 
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Perrotfish said:
Are you going to stop prescribing ACE inhibitors and metformin for patients who don't exercise?
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No, because once you have hypertension or diabetes it's very very hard to get rid of it.

Having the flu once doesn't predispose you to getting it every year.

Edit: And that's a pretty terrible analogy. You do realize that the flu isn't a chronic disease, right?
 
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deuist said:
I like the idea of offering all non-critical patients flu vaccines in the ED. The request could be automatic from the nurse just like "Do you feel safe at home?" The order could also reflexive so that the doctor does not have to get involved. The universal vaccination against influenza from the ED makes a whole lot better sense than when New York made every physician offer HIV testing.
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Great, and then we could give everyone pneumovax, update everyone's tetanus, give zostrix boosters, and update all peds patients who are missing vaccines. Might as well, you know, since they're in the ED anyway...
 
BAM! said:
Great, and then we could give everyone pneumovax, update everyone's tetanus, give zostrix boosters, and update all peds patients who are missing vaccines. Might as well, you know, since they're in the ED anyway...
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Again, much of what you mentioned does not need to involve the physician. When I bring my kid to his pediatrician's office for vaccines, we never see the doc or PA. The injections are automatically given by the nurse and then we're sent home. If I see someone in the ED for an ankle sprain and then discharge, the nurse could offer a flu vaccine while applying the splint. Preventing death with vaccines is much better for population health than most of what we do in the ED.
 
deuist said:
Again, much of what you mentioned does not need to involve the physician. When I bring my kid to his pediatrician's office for vaccines, we never see the doc or PA. The injections are automatically given by the nurse and then we're sent home. If I see someone in the ED for an ankle sprain and then discharge, the nurse could offer a flu vaccine while applying the splint. Preventing death with vaccines is much better for population health than most of what we do in the ED.
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Agreed. Except that EMTALA requires the MSE, and while the law does allow for nurses to provide it, most hospital policies require a physician or MLP to do it. So we cannot remove the physician. Sure, the nurses can SDO it, but it's unlikely I'm sure.
 
Dr.McNinja said:
Agreed. Except that EMTALA requires the MSE, and while the law does allow for nurses to provide it, most hospital policies require a physician or MLP to do it. So we cannot remove the physician. Sure, the nurses can SDO it, but it's unlikely I'm sure.
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The doc would still see the patient for MSE purposes, but once my job is done, the nurse can inquire about vaccine needs.
 
GeneralVeers said:
Exactly. I don't care about all the nursing garbage. Let them deal with it.
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How many other things could the nurses deal with that they include you for? Doc, can room 8 go eat/pee/breathe/survive? Did you put in the order?
 
The dumbest nursing order protocol of late is that we have to put in a "nursing communication" order for the nurse to be able to give the pt a work excuse.
 
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Speaking of nurses. I had an overnight shift recently and one comes up and asks me if I wanted to get another pro-BNP on my CHF exacerbation that I had ordered lasix on. "She's pee'd so much! I just KNOW the BNP has come down by this point!" I just sat there staring at her with this dumfounded look on my face. She goes "The BNP shows how much fluid they've got, right?! Doesn't it come down after lasix?"

And to think, these are the same nurses that go on to become DNPs....
 
TooMuchResearch said:
Can they verbal that nursing communication order?
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Nope. To the best of my recollection, the whole thing started over a year ago when a pt came back to the ER for a work note and asked one of the triage nurses for one. They ended up giving him a week off and put it under the name of a different physician who wasn't even on shift and hadn't even seen the pt that day. So, nurse gets in trouble and what's the solution? Physicians are to order nursing communication orders specifying work excuse parameters. It's stupid. Prior to all of this, we just did verbals.
 
I don't give a **** if the nurses write notes saying the patient should be out of work forever.


Also, our work notes say on the bottom that we only write for 72 hours and then they need to see someone else.
Groove said:
Nope. To the best of my recollection, the whole thing started over a year ago when a pt came back to the ER for a work note and asked one of the triage nurses for one. They ended up giving him a week off and put it under the name of a different physician who wasn't even on shift and hadn't even seen the pt that day. So, nurse gets in trouble and what's the solution? Physicians are to order nursing communication orders specifying work excuse parameters. It's stupid. Prior to all of this, we just did verbals.
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TooMuchResearch said:
I don't give a **** if the nurses write notes saying the patient should be out of work forever.


Also, our work notes say on the bottom that we only write for 72 hours and then they need to see someone else.
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I think it should be automatic with DC instructions: "Here's your standard 72 day work note you lazy SOB"
 
I've been wanting to make a thread about how you guys handle work notes, I can't stand them but occasionally it's legitimate. I just play it by ear, sometimes I say no (although that's rare), sometimes it's a day or two.

And I never give work notes for things that happened in the past.....

"doctor I've been out for three days with my cough. Can you write me a work note saying I've been out for that time?"

NEVER!
 
"{Name} was in the emergency department on {date}."

Doesn't have to say anything else unless it really seems like they can't go back.
thegenius said:
I've been wanting to make a thread about how you guys handle work notes, I can't stand them but occasionally it's legitimate. I just play it by ear, sometimes I say no (although that's rare), sometimes it's a day or two.

And I never give work notes for things that happened in the past.....

"doctor I've been out for three days with my cough. Can you write me a work note saying I've been out for that time?"

NEVER!
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TooMuchResearch said:
"{Name} was in the emergency department on {date}."

Doesn't have to say anything else unless it really seems like they can't go back.
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Yup I hear ya. I do that sometimes too. It's the colds who want time off work and they are wait-server. Seems somewhat reasonable to not be serving food while you are coughing. But for how long?

What about pink eye? I tell parents all the time I don't care if the kids goes to school with pink eye. It's bothersome but never life threatening. However schools have some protected interest in keeping other kids safe and healthy. So the schools may want them out. But for how long?

Or some dude that throws his back while lifting something at work. I don't mind giving him some time off (maybe a day or two) but for how long? I don't know when he is going to get better. Might be 2 days, might be 10. But I'm not going to write a note for 10 days.

The problem with all of this is that most people don't want to work appear not to want to make money. And that is the most irritating thing. I love taking care of patients who chop off their finger at work and want to go back to work immediately!
 
thegenius said:
Yup I hear ya. I do that sometimes too. It's the colds who want time off work and they are wait-server. Seems somewhat reasonable to not be serving food while you are coughing. But for how long?

What about pink eye? I tell parents all the time I don't care if the kids goes to school with pink eye. It's bothersome but never life threatening. However schools have some protected interest in keeping other kids safe and healthy. So the schools may want them out. But for how long?

Or some dude that throws his back while lifting something at work. I don't mind giving him some time off (maybe a day or two) but for how long? I don't know when he is going to get better. Might be 2 days, might be 10. But I'm not going to write a note for 10 days.

The problem with all of this is that most people don't want to work appear not to want to make money. And that is the most irritating thing. I love taking care of patients who chop off their finger at work and want to go back to work immediately!
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I just don't care. I write the work note for everyone. It's not worth even one second of neuronal processing to deal with this crap.
 
Yeah who cares about work notes? Not this guy. No skin off my back if I give them a million days off work, and if I don’t give the patient what they want, they are more likely to complain.


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I don't understand why nurses even ask if patient can have a work note. If they wanna call out of their job cause of sniffles and not get paid that's their choice.

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More info about the lame Tamiflu med. Apparently it's one big placebo. This trial came out in Lancet 2020. Apparently if you have flu like symptoms (and not even confirmed flu) Tamiflu makes you feel better by one day.

I guess medicine makes people feel better overall. Why can't it be ethical just to prescribe a placebo drug and not tell people? Such a shame.

Lancet. 2020 Jan 4;395(10217):42-52. doi: 10.1016/S0140-6736(19)32982-4. Epub 2019 Dec 12. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial.

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