A Bonanza of Influenza
In a flu season of epidemic proportions, clinicians have had to assess and treat a high volume of patients, often without the luxury of a flu test. Colleagues in hard-hit areas share their survival tips.
“A lot of them are coming in with viral pneumonia,” she reports. “It quickly develops in them. They come in and they’re short of breath, they have really bad oxygenation, and they require a day or two in the ICU.”
Another observation that O’Rourke has made, and which has been noted extensively in national news broadcasts, is that “it’s a lingering illness this year; people are sick for a week, two weeks. Even though they may start to feel better, they’re still washed out, coughing, with chest symptoms that they need to pay attention to.”
To Treat Or Not To Treat
In some areas of the country (including Boston, where a state of emergency was declared), practicing clinicians have been so overwhelmed with patients that some have abandoned flu testing and decide to initiate antiviral treatment without a validated diagnosis. As Killeen says, “If it looks like flu and acts like flu, then people are going to treat it with [oseltamivir].”
With older patients, O’Rourke says, “I’m going to err on the side of giving it to them as opposed to not, because they are so vulnerable. A lot of them have comorbid conditions, such as diabetes or COPD, which puts them at greater risk. Any folks with chronic illnesses—asthma, HIV—you want to be more aggressive with their management.”
However, there may be patients for whom the gastrointestinal side effects of the medication do not sufficiently outweigh the benefits of a slightly reduced course of flu. “In many situations—and especially if we haven’t started treatment within the first 48 hours—we don’t necessarily recommend using an antiviral medication,” says Barry. “Even if we’ve caught it within 48 hours, if the child is otherwise healthy with no major underlying heart or lung issues, often I’ll leave it up to the parents.”
Barry has also learned to emphasize what antiviral medication can and cannot do in discussions with patients and families. “We try to make parents aware that it’s not a magic bullet,” he says. “It won’t cure the flu, boom, right there on the spot.”
While Killeen also supports the appropriate use of antiviral medications, he notes that there are some patients for whom clinicians will want to be more cautious about prescribing them. “A sickle cell patient, for example—if that person comes in with the flu, you have to think about other encapsulated organisms, like pneumococcus, that could be potentially detrimental to the patient, pending their vaccination status,” he says.
Clinicians have to rely on their clinical judgment when they don’t have the time or resources to confirm a flu diagnosis with a test. “If a pediatric patient comes in with petechiae and fever, that tells me, ‘No, it’s probably not the flu; we should be thinking about something else going on,’” Killeen says by way of example. “But absent other contradictory physical exam findings, then I would say we would treat [with antivirals].”
A Word (Or Two) Of Advice
For clinicians who have seen no abatement of flu season, or whose regions were late starters, here is some advice from your colleagues:
• Get your flu shot if you haven’t already. “Its efficacy varies, but in healthy adults you’re getting between 60% and 80% immunity,” O’Rourke notes.
• Wash your hands. “The quick alcohol hand rubs are great, but in flu season, I love soap and water,” says O’Rourke.
• Protect yourself and your other patients. Wear a mask. Ask patients with suspected cases of flu to do the same. If possible, do what Barry and his colleagues do: “We have anybody who has flu-like symptoms come in a separate entrance to our office, so we don’t have them in our main waiting area.”
• Stay home if you’re sick. This isn’t quite the no-brainer it seems. “[Clinicians] will come to work when they’re deathly ill, because they don’t want to burden their colleagues, they don’t want to miss out, and there’s a certain pressure for us to be the ‘soldiers’ who carry on,” O’Rourke observes. “If we’re sick, we’re not doing anybody any favors by coming to work. I think the better part of valor is to stay home and take care of yourself. We can’t be good caregivers to others if we can’t care for ourselves.”
