Influenza Complications Get Personal

My six year old had a classic case of influenza all with every other member of the household save me who received vaccine. She had an abrupt onset of a fever, cough, fatigue, and aches which lasted five to seven days. Her fever went away and after missing a week of school she went back to school for a day or two before the fever returned.

Then the cough returned. A normally perky and playful first grader became sluggish and tired. Of course her Dr. Daddy had gone to a CME while she had turned for the worse so her Mom took her to her family doctor her quickly referred her to the ER. Chest x-ray showed bilateral infiltrates with a clear predominance toward the left lower lobe. Not only did she have a textbook case of influenza, but now she had a textbook superinfection.

Obviously I rushed home and now sit with her in her hospital room on the pediatrics floor blogging. She's been hospitalized for two days now and thanks to some chocolate pudding therapy and a third generation cephalosporin is doing well and should go home today.

All of this for just a little flu? Influenza is not a benign disease. To this the vaccine is riskier than the disease is just irrational and foolish. As equally as irrational is why we continue to have vaccine supply issues.

The Country Doctor

Sick of Flu

I made it through the week and a half or so it takes for the H1N1 influenza vaccine to take hold, but the flu has still taken quite a toll on me.

Normally I refer to this time of the year as my Hunting Season Lull, but with at least a half dozen patients with influenza-like illness in my schedule every day I'm not sure I've ever been quite so busy. Fortunately most of these folks just need to go home, rest, and drink plenty of fluids. If nothing else this year has reminded people how bad it feels to have true influenza apart from what we casually refer to as the flu. Unfortunately I've admitted two patients to the hospital with influenza as well. One was a four month old baby who was more precautionary and the other a middle age woman who stayed four nights with a nasty COPD exacerbation triggered by H1N1. Hopefully she will see this as a teachable moment and finally quit smoking.

We have been lucky at work with only one nurse out for a week with the flu. She received her vaccine only a few days before coming down with symptoms herself. If she had been able to receive her vaccine a week earlier as I did, she likely never would have become ill. The rest of our staff is hanging in there, and all but one, my stubborn nurse, received vaccine.

Our county still appears to be short supply of vaccine at least compared to one neighboring county. We received enough for our staff and pregnant patients. To date, these twenty or so doses, for which we had to beg and plead, are all we have received for our some 3,000 patients.

Where H1N1 has taken its greatest toll on me, however, has been on the home front. My wife and three kids all have come down with it and are now in various stages of recovery. While the struggle to balance one's personal and professional life is always present, trying to meet the needs of people with influenza at both home and work has been both mentally and physically draining.

It's been so tiring in fact that you would think I had the flu.

The Country Doctor

Flu, Flu, Flu

It is all the buzz lately, so I thought I should probably jot down a few notes on what has been going on out here.

Like many areas, people with influenza like illness are everywhere and most of these folks probably do have true H1N1 influenza, but I tend to place then in the "like" category since tests done in clinical practice aren't the most helpful, so few are performed. At least a half dozen of these folks are on my schedule everyday and all are masked and asked to sanitize their hands before even having a seat in the waiting area. Fortunately none no one has required admission to the hospital.

Vaccine for H1N1 is in terribly short supply around here in part due to the widespread manufacturing issues and in part due to our county health department. Rumor has it they have been hoarding what little they have received in order to conduct school clinics leaving the CDC designated priority groups of pregnant patients and health care workers without access. Don't even get me started on this.

Fortunately I also practice in another county, so yesterday I crossed the county line and received my H1N1 vaccine without any problems. Given the number of exposures I have undoubtedly had over the past few weeks I'll be quite thankful if I don't come down with the illness prior to the vaccine taking effect.

The Country Doctor

Don't Try This At Home

In medical school and residency we are frequently reminded to be compassionate and empathetic in our patient encounters. Be a good listener and don't rush to judgement are frequent mantras. This is a good rule for practice, but there is a patient type out there for which this approach should be completely thrown out the window.

One such patient came to see me yesterday for chronic shoulder pain. Years of wear and tear commercial fishing had left his rotator cuffs frayed and battered. He came in to discuss his MRI findings and to discuss treatment options including an injection, physical therapy, or referral to an orthopedist. He didn't like any of my ideas.

Now ordinarily the correct approach is to get a broader patient perspective at this point and see what sorts of barriers they have to these options. For example, had they had or known someone who had a bad experience with a steroid injection in the past? Could they not afford time off for surgery?

I learned long ago with this salty old guy he didn't go for any of that. Be too nice to him and he'd consider it patronizing. It would just add to his anger. What he responded better to was his doctor to being brutally blunt and borderline rude to him.

"Well, what do you expect me to do here?" I blurted out. "You know you come to see me wanting my opinion well here it is. You've waited how many years to have this looked at? I don't think this is getting better on its own. I think you should try one of these ideas. If you don't it's your choice, but you ain't gonna get any better doing what you're doing."

Upon getting off my soapbox he sat there in thought with a content look on his face feeling like his doctor really cared enough about him to tell him off. He decided to try a little therapy and if that didn't work he'd think about his other options.

This communication style must be done very carefully as it will anger offend far more than it will work for, but when you find the right patient it can become a quite satisfying patient encounter. Not only does the patient feel well cared for in the end, but I must admit, it can be a therapeutic venting for the physician at times too.

The Country Doctor

The Health Fair

Spent Saturday representing our office at the area health fair held at the county fairgrounds. Forty of so "vendors" from various medical offices, health agencies, or hospitals set up booths and displays offering information, some health screening, and generally showing off their stuff.

Since we are the only physicians in our half of the county who provide maternity care, this was a natural topic for my display. I must say, for a novice booth maker I definitely impressed myself with this one. It was multi-media with looping DVD on prenatal care and hands on in the form of a series of fruits and vegetables meant to represent various ages of fetal gestation. All of this was in addition to various pieces of literature on pregnancy in English and Spanish and, of course, some candy for the kids. It was difficult to find a food item for a term baby, but I went with the largest butternut squash I could find which came in around 7 lbs.

Many of the people who came through I already knew, but I certainly meant some new folks as well and probably picked up a couple of patients. My booth was near the hospice folks, organ/tissue donation, and the dairy princesses, so we all made a little small talk throughout the day long event.

If nothing else my Saturday raised a little awareness about the importance of good prenatal care and gave our practice a little good PR. At best, however, a new booth making talent has been discovered.

The Country Doctor

The Cycle Continues Epilogue

A final update on the post, "The Cycle Continues". In this sad race the baby arrived in this world four hours before the young woman left it. The baby was delivered in a room only with the mother, a two nurses, a pediatrician, a resident, and myself present. The young woman may have not felt loved in life, but she was surrounded by family and friends at the time of her death.

This morning when I rounded on the new mother I asked her if she planned to breastfeed as is my custom. Her response, "Oh, no. I smoke cigarettes and I don't want my baby to be exposed to any of the nicotine through the breast milk." How considerate.

The Country Doctor

Gut Instinct

It's hard to say what we often refer to as gut instinct really is. Is it some type of paranormal sixth sense, or perhaps it's just a subconscious collection of past experiences that we apply to the situation at hand? Whatever it is, one would hardly find it in the medical literature and one can hardly consider it to be evidence based medicine.

A very nice and ever so slightly demented woman in her early 90s was admitted this weekend with some fairly nonspecific abdominal pain, nausea, loss of appetite, and dehydration. She had a somewhat similar episode three months ago, but didn't feel the two were related. What did concern her, however, was that she was dying. In fact when I admitted I asked her her thoughts on what the diagnosis was and she said, "I think I'm dying."

We did some simple blood tests and x-rays and noted she had some mild pancreatitis and a couple of gallstones which could have been at play. The IV fluids were tuning her up and she was clearly clinically improving. There just was something unsatisfying still though. My gut instinct told me there needed to be more done. She was certain she was dying and I still really didn't have a lock on what process was going on here.

The residents I was working with thought I was crazy to go to the time and expense to order a CT on the abdomen of a patient clinically improving as she was. Fortunately in this situation I'm the attending and they are not. Unfortunately for the patient she appears to have a cholangiocarcinoma--a difficult to treat cancer of the biliary system and often involving the liver and pancreas.

We have some difficult conversations ahead today, but now at least we know what is wrong. I'm glad I trusted the patient's gut instinct about her gut.

The Country Doctor

The Cycle Continues

On call this weekend and find myself bouncing between the ICU and L&D today. Upstairs is a woman in her early thirties dying from the alcohol and tylenol she used to heal the physical and emotional wounds from her boyfriend's beatings. Downstairs another young woman has walked in to have her baby without any prenatal care. Best estimate she's about 36 weeks, or a month before her due date. Preterm labor and no prenatal care unfortunately is almost diagnostic of drug use during pregnancy. Her last child was taken away from her and is in foster care.

I find myself playing a sick guessing game. Which will happen first? Will the baby be born or will the woman die? The cycle continues in many ways.

The Country Doctor