Letters from Maine

Hidden in the crowd


According to the newspaper headlines, we are in the middle of an influenza epidemic that is worse than usual. After a closer reading of the reports, however, a more accurate description of the situation would be that there has been a recent surge in hospitalizations, visits to emergency departments and doctors’ offices, and school absenteeism. Since most people who are ill haven’t been tested for influenza, one can really only say that we know that there is influenza in the community and a lot of people are sick.

Regardless of whether there is influenza hip hopping around, winter is a sick time of year. Although public health officials seize the opportunity to encourage vaccination, the truth is that influenza has many fellow travelers. For the first time that I can remember, press releases have been more candid and referred to "flu-like illnesses." This season we have been seeing a large number of cases of gastroenteritis, possibly caused by norovirus. Here in Maine, this cohabitation is especially confusing because the natives refer to any illness in which vomiting predominates as "flu."

The bottom line, according to the collective mindset, is that everyone has the flu. This scares me more than the fact that there is influenza around. This is a busy time of year for a primary care physician, but I don’t mind being busy because I enjoy what I do. However, I find the flu-epidemic mentality to be anxiety provoking because, when there are more donkeys galloping through my office, it becomes that much more difficult to find the zebras hidden in the thundering herd.

Are our triage nurses adequately trained to deal with the surge? Do they have algorithms and templates that will allow them to identify the sickest people? Not every caller who has fever, headache, a slight cough, and "feels like crap" has an influenza-like illness that can be watched at home for a day or two.

One particularly busy Monday last week was typical. Most patients had simple upper respiratory infections. One or two had rapid test–positive influenza and a few had gastroenteritis. In the late afternoon, though, I saw an 8-year-old girl whom I had known since birth. Her routing sheet listed her chief complaints as "fever, achy neck and shoulders." I was surprised that she had slipped through the phone triage gauntlet.

When I walked into the exam room, it was difficult to tell that the child was the ill because she was sitting quietly on the exam table. However, as I began to examine her it was clear that an effort on her part to extend her neck created extreme discomfort. As I expanded my history, I discovered that, like most patients with influenza, she had some sore throat at the onset of the illness, but her neck pain had quickly become her major complaint.

Getting a good look at her oropharynx was out of the question, but I was able to gingerly obtain a throat swab sample that was rapid-strep positive. One or two calls later she was on her way to our tertiary care medical center, where my suspicion of a retropharyngeal abscess was confirmed and treated surgically.

Before she left for the hospital I quizzed her mother, whom I had always known to be concerned and observant. In the past she had never been afraid to come in and be told that nothing was seriously wrong. I was surprised that she had waited 2 days to call and bring her daughter in. I reminded her that we have always had weekend office hours.

She explained that there had been so much talk and media attention about the "flu epidemic" that her usual instincts had not penetrated the haze of information about influenza. Luckily, all’s well that ends well, but this young lady’s illness was a reminder to all of us that not everything that quacks is a duck.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail Dr. Wilkoff at pdnews@elsevier.com.

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