Queens, a borough of the city of New York, seems to be a hotspot for swine flu and a New York Times reporter on the city beat, Anemona Hartocollis, has been writing very astute and perceptive pieces from there. Yesterday she had one on the problem posed by the "worried well" who are flooding Emergency Rooms in quest of reassurance. Articles about worried parents who bring relatively well kids to the Emergency Room (ER) are not uncommon. They usually include interviews with harassed and overburdened emergency room doctors and nurses dismayed at the unnecessary demand and its consequences for those who are true emergencies. But Hartocollis's reporting is unusual in that it has some real insight into why people are doing this:
Fathers came home from work, mothers thought twice about putting their children to bed with a fever, and as if under mass hypnosis, they headed for the hospital.[snip]
As officials announce the latest school closings each day — eight new ones on Thursday — and public officials tread a delicate line, trying to seem on top of the disease while not spreading panic, parents have turned to emergency rooms as the arbiters of the maddening ambiguity of the disease. To worried families, the H1N1 virus is like a bogeyman in the night, and the trip to the hospital the equivalent of checking under the bed.
Is it a deadly scourge, a Stephen King novel come to life, or only a mild inconvenience? The emergency room is the place where public relations and public fears confront science, where families go to find peace of mind. (Anemona Hartocollis, New York Times)
I have no sense of panic about this outbreak. But my two grandchildren have coughs and their daycare center sounds like a pest house, with children throwing up and running high fevers. The two little ones seem otherwise fine, but I had to convince my daughter she needn't take them right off to her HMO's urgent care site. Yet with all I know intellectually about this, part of me was still anxious. Influenza is mostly a self-limited illness but I respect it. I told my daughter and her husband to keep an eye on things. Kids can go sour quickly.
It's a simple fact that the surge in demand by those not sick enough to warrant the use of scarce medical resources (the time of emergency room personnel) is unavoidable and has to be part of any planning. Hartocollis reports that visits to the Schneider Children's Hospital ER in Queens quadrupled since last Friday. Most city ERs are running at capacity during normal times and this constitutes an overwhelming demand. Because of this, the onerous trip to the emergency room brings nothing tangible. Unless the patient has an underlying medical condition and signs of an influenza-like illness, they aren't being tested nor usually given medication.
But medication and testing aren't the real objectives for most parents. The real objective is some peace of mind. That's not the same thing as panic and it won't be cured by trying to reassure the public with hopes of "avoiding panic." Instead we should look for better ways to allow people to meet the objective, for example, by temporary flu clinics to triage cases and reassure the non cases.
Hartocollis has it exactly right. A trip to the ER is the equivalent of checking under the bed for the bogeyman. It can't be prevented. It can only be planned for.
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So for years (literally) we have taken the approach that taking care of your self at home (with phone health care privider advice) is the best approach. Why? Because in a more severe scenario you can't get seen and in a milder scenario, you don't need to be seen.
This would be a perfect opportunity for PSAs on the topic. But what we do have is manuals and info we and others have put together:
Citizen's Guide
http://www.newfluwiki2.com/upload/FluManualv2_0_revised.pdf (.pdf)
Get Pandemic Ready (html, also available in .pdf)
http://66.236.6.202/html/First_Aid.html
http://66.236.6.202/html/Home_Treatment_Resources.html
American Red Cross
http://www.adamscountyredcross.com/pandemic.aspx
CDC has also put out one... quietly:
CDC
Interim Guidance for H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home
http://www.cdc.gov/h1n1flu/guidance_homecare.htm
I think your idea of setting up temporary flu clinics for the purpose of triage is a fantastic idea. It sounds like a smart move from the standpoint of public health, and it also sounds like a prudent fiscal move. Emergency room visits are costly, and I would imagine not terribly efficient for dealing with vast and increasing numbers of "the worried well."
You scientist-types deserve your own "wishlist website" upon which great ideas are pitched to the public for funding. (Perhaps scienceblogs.com could host it!) Science has always provided the American taxpayer with a commendable return on investment; a "big bang" for our taxpayer buck, if you will!
Remember, the internet has not only transformed our access to you, it has transformed your access to us--the layperson and average taxpayer. By and large, you folks are more convincing than the politicians who speak on your behalf. Please continue to use this platform to inform and engage us--the more I understand about science and the scientific method--the more likely I am to pressure my representatives to get you the funding you need.
melbren: Thanks for the kind words (appreciated as always on a blog with pseudonymous bloggers). In June 2005 we started something with just that idea, The Flu Wiki. It split into two parts, a Forum and the science/reference part. Both are accessible from the Forum portal here.
And let's not forget that millions upon millions of Americans simply have no other option for being seen, not just on the weekends or at night, but ever. The "worried [relatively] well" flooding in may be disproportionately those with insurance. But how long before we hear of some truly sick person being seen too late and dying because they didn't have a doctor or insurance?
For all we know, it's happened already. It happens every day in this country.
What I don't get is why we're using 19th century technology for this: physically going to an emergency room. (Very smart, too to go to the place where you know for sure the sick people are.) Using the phone makes much more sense, and leveraging today's technology would be even better.
An online service that knows about people's medical history and (swine) flu incidence in the places where they live, go to school and work would be able to tell people when they shouldn't worry and when they should seek medical advice based on any symptoms entered quite accurately.
Iljitsch: It's called WebMD. Last time I used it it suggested I might have a heroin addiction. (Hint: No.)
In all seriousness, I don't think you can say "don't worry" just because there aren't any confirmed cases in your school or workplace yet. Somebody's got to be the first, after all. And while I don't know what kind of radius they're talking about when they say they're only testing for it in "new places" now, my guess is a most workplaces aren't big enough to be a new place.
I think some of the screening could be done over the phone, though. But so far it seems it would take a real live nurse or doctor to sort symptoms. Electronic algorithms may just not be sophisticated enough yet.
Thursday night at 10 PM I got a call from a patient whose 14 yr old daughter had a sore throat, cough and fever to 103.6 F.
In Georgia where the CDC has determined the Mexican Flu is "widespread" the obvious diagnosis was influenza.
She started Tamiflu and the mother pushed fluids and today she is better.
What was remarkable to me was the fact that the mother was an informed healthcare professional. She knew about flu and especially pandemic flu and was simply unable to think straight. She told me she thought her daughter had Mexican Flu in her first sentence on the phone but otherwise was unable to cope, crying, confused and all at sea.
I know this women well and she is a rock solid administrator. So, it was of interest that she reacted this way. She is well informed about pandemic influenza as well.
What this encounter says to me is the importance of people having a plan in place, in their homes ready to go should one of their family members become ill with pandemic flu. What is key here is to get the information now before you need it and stockpile the meds and other items required for flu treatment ahead of time. Also, read the flu treatment booklet or booklets you download from the sources provided above by DemfromCt.
You need to prepare ahead of time in this way so that when necessary you will be able to know what to do. At 10 PM, you don't want to try and find everything you need.
WHAT DO YOU NEED? Do you know? If not, please take the time to find out now, get the stuff so you have it one hand and are ready for the possibility.
Do it now. We maybe on the cusp of a pretty intense increase in cases of this "mild" version of Mexican Flu that might not look so mild in a few weeks.
Furthermore, as the medical professionals have all been warning on this site and all across flubloggia, in the fall the Mexican Flu could return again to the northern hemisphere in an entirely new and more serious form. The time to get ready for the next few weeks and the next few months is now. Please do not delay.
Grattan Woodson, MD
In other flu news, ProMed today makes it sound like swimming in duck pucky is the next-generation low-budget vaccine against H5N1.
(H5N1 antibodies in Cambodian teens without history of serious illness, known to have been swimming in water frequented by H5N1 positive ducks.)
Yes, the pdfs and Flu Wiki are great, but trust me, people need to do some hands on like a First Aid course. I've told people about these pdfs till I'm blue and they have NOT downloaded them. I hand them out even but they get stuffed in a stack or drawer somewhere. Lots of people DO NOT HAVE COMPUTERS. Lots do not have a TV.
Get out in the real world and out from behind the desks! It ain't gonna happen like you think. Ask any EMT or First Responder just how helpful a doctor is on the scene of an accident in the middle of nowhere. They are useless. Why? Because they haven't the hands on training for THOSE situations.
Ditto for the public. They will need hand holding and town meetings and demonstrations and volunteer help. It's a job for the Red Cross or the barefoot doctors.
Pdfs and online help are correspondence courses. Most people never finish them.
I'd like to add my thanks to this site for providing panic-free information and sensible advice.
I have a question, too. I read that "In 72 of the 80 deaths, the first display of symptoms was before April 23". Also, I remember reading somewhere that incidences of seasonal flu overlapped swine flu, particularly at the beginning of the outbreak. And I read this story, about a man who died, and who "tested positive for several strains of flu". I haven't seen any followup to this story.
Is it possible that in other severe cases there could have been more than one strain of flu present? Would that be picked up in testing for swine flu? And could that be why most cases are 'mild'? Would the presence of more than one strain of flu make symptoms more severe? I'm in Japan, where all cases have been mild, and I'm wondering whether that's because the flu season was pretty well over when swine flu arrived.
Sorry - forgot the link for the first quote: In 72 of the 80 deaths, the first display of symptoms was before April 23.
Dear BadAunt, alas it is not so. They deaths in Mexico were due to the Mexican Flu not the seasonal flu. Why? Because the usual flu season was pretty much over before the death rate from flu began to rise in mid March and the victims of the flu were those typical of pandemic flu; aged 15 to 45 years rather than the very young and very old as is seen with seasonal flu.
GW
BadAunt--a mechanism like that could alter the mortality rate, but if 'the doctor''s information is correct, then even though its a reasonable explanation, it isn't what actually happened. But your thinking process is okay.
Supposedly the Mexican virus is genetically identical (or more likely, near-identical) to the US strain. So there has to be an environmental or host factor involved.
To me the most likely explanation is that there were far far more mild cases in the community than were ever identified. But poor underlying health in the population of Mexico could be to blame. Maybe those who died had an unusually high parasite load, or Chaga's disease that hadn't yet manifested with symptoms, or latent tuberculosis--there's a lot of crud running around Mexico unchecked. Someone suggested air pollution; I wonder if smoking might play a role?
We just don't have enough reliable information out of Mexico to really know what happened there. All we can do is be glad that in every other country, this virus has elicited illness comparable to seasonal flu, save for the age distribution.
Thank you for these responses. Your explanations make sense, unfortunately. It seems particularly likely that mild cases were not picked up very much in Mexico. Here they seemed to be testing almost everyone.
Schools and universities (in Osaka and Kobe) reopen tomorrow, and I am not happy about it - and not just because I'm a teacher, either! Closing them worked to slow the spread, but the classroom is the perfect place to get it sped up again, and I don't particularly want to be around a whole bunch of unhygienic teenagers. (Forget what you read in the media about Japanese kids being hygenic. The girls generally are, but the boys - particularly the ones living away from home for the first time - are a different story!)
I work at two universities. One in Osaka and one in Kobe.
Thanks again to bring such a subject out.
Because I belonged to different Unique Parents Associations, when one of our child is sick and your network of friends or relatives is limited, having a child presenting symptoms can be indeed very stressfull.
Such cases have been made widely public up here in Quebec and the Gov because of many other reasons, have decided to create the 811 line. You call 811 and a RN in front of a computer answers the phone, she has protocols of questions and recommendattions for the caller asking for medical advice. In no way they pretend to make diagnostics but most of light and easy cases finds solution via 811.
It is cheap to created and it is expected to be very usefull in a crisis.
Protocola of questions and recommendations where of cource made by Medical Practitionner autorised to make diagnostics.
Because we have a free helth care service up here, organisations do not fear as in US to be sued for this or that.
Just a service that is very appreciated. (Btw it serves as a centralised collectors of datas on contagious diseases too)
Snowy
Snowy Owl describes one useful method of dealing with the bogeyman of human anxiety. And phytosleuth brought up an important point:
"They will need hand holding and town meetings and demonstrations and volunteer help. It's a job for the Red Cross or the barefoot doctors."
My first thought as I read this post was "what about school nurses and doctors?" Wouldn't that be one possible system to utilize in a serious epidemic situation?
Couldn't plans for dealing with pandemics include detailing medical personnel to beef up whatever school-health system exist - widen their remit to family members of pupils, provide information and "hand-holding".
It just seems totally absurd, especially in a situation where a community is hit by an epidemic, to use emergency rooms for dealing with any level of ILIs. And just public awareness campaigns will NOT be enough, phone-hotlines is a minimum, but in a situation where people are scared - and have a reason to be - there needs to be some kind of system for dealing with that.
phytosleuth, thanks for the lively comments! I train EMTs and paramedics, so I'm glad they are appreciated. I'm not an academic and I haven't had a desk job in 20 years.
The .pdfs and web sites alone can't do it. They are best for pre-loading and pre-gathering( some of the small towns near me have emailed them to every town resident as part of a 'put it away until you need it' kit. Others are handing out another version at the local library gratis. However, coupled with a 1-800 line (see Snowy Owl's comment), they can be very useful.
And of course the same is true for a just in time delivery. This isn't just academic speculation.
Another thing that's useful is what NYC finally did!! They defined "underlying health condition".
what's with the first bullet? Where's the evidence that
⢠People over 65 or under 2 years of age
have an underlying risk for A (H1N1)?
nycflu, something like 9 out of 10 deaths from seasonal influenza are usually folks over 65. That's where that stat comes from. Influenza for these folks usually tips the scale for them b/c they have other underlying conditions like heart problems or lowered immune competency. The swine H1N1 seems to be affecting a young age group so far. But it could change and elders could be at risk pretty fast again.
DemfromCT, sorry I was a bit shrill. Am frustrated that people in my state are totally non-plussed and not prepared. I know not everyone is behind a desk. Lots of good people are working hard on this. I just don't want to see last minute preparation here. That would be a panic then.
We've forgotten how to do simple basic things, from canning vegetables to basic hygiene. Even after all my tirades, my mom-in-law asked to taste my beverage the other day...out of my glass. I reminded her we were in a pandemic/epidemic but, argh...I let her sip! I can't do this alone. Everyone needs to be on board.
BadAunt: We really don't know what role, if any, other flu viruses circulating at the same time may have played in the Mexico situation. Perhaps we will unravel that at some point.
nycflu: I think the inclusion of the very young and the old is based on these as risk factors for seasonal flu. It is still not certain what the age distribution is for this flu (it is still possible that the elderly are at risk, but as the evidence comes in it seems less likely), and in general older people have more underlying medical conditions that when combined with flu might make them more vulnerable. At this point it seems wise to include them. While we may not be at greater risk relative to other age groups, it is plausible we should still be at greater risk.
The 2009 H1N1 flu is spreading from the US to other places, especially from NYC and San Francisco. Can the US do more to prevent this?
I had to go to the ER in Brooklyn two days ago for a minor bike accident, and, man, were the doctors and nurses helpful and friendly. I feel like everyone I talked to was so tired of seeing kids with fevers, they were very happy to treat a "regular" ER case. :)
And yes, pretty much 75% of the people in the ER were children wearing face masks, some of them not even visibly sick. One little girl walked in with her mother, looking healthy as a horse. Her mom walked straight up to the nurse on duty and said "Her doctor recommended that she get tested for swine flu", and then sat down and patiently waited the four hours it took for them to be seen. The little girl didn't so much as cough the whole time, she just sat there with her face mask, reading a book.
It really made me wonder. Why would you bring an otherwise healthy child to a room full of coughing, sneezing, possibly swine-flu-infected people in the beginning of what seems to be an epidemic? People amaze me.
I think the simple answer is "No".
As long as people board commercial passenger airlines that hop oceans in tens of hours of flight time, a stealth infector like influenza will cross borders, and even oceans, with relative ease.
That's how SARS escaped from its epicenter in Guangdong Province to begin with. And it's how SARS then went from Hong Kong to Canada and Japan and Vietnam.
And SARS is a piss-poor infector compared to airborne seasonal influenza.
@Sylvia:
Because people are ignorant despite all we have tried to do to educate them. Some folks just don't/won't pay attention. (The line between ignorance and stupidity blurs here.) You also have to wonder about her statement that 'her doctor recommended she be tested for swine flu'. If her doctor thought she needed to be tested, I can't imagine that her doctor couldn't or wouldn't test her him/herself. I know for sure that in my state, although we were screening submissions to our state lab, anyone with appropriate symptoms and history would be tested. (Now that we have established the presence of the virus circulating in our state, we are only testing hospitalized cases. The same may be true in NY.) More likely, if the physician thought the girl had novel influenza, (s)he would have started treatment if the child met the guidelines for treatment. http://www.cdc.gov/h1n1flu/recommendations.htm I'm guessing that since this girl didn't have the appropriate symptoms, mom didn't get the answer/action she wanted from the physician and went for plan B. Or else, she just lied to the nurse from the get-go.
Caia said above: "I think some of the screening could be done over the phone, though." Tona Aspsusa made a similar point as well.
My wife was concerned about our child a couple weeks ago. I convinced her to call our insurance Nurse Line and that worked. She knew it wasn't time to see a doctor and what she needed to watch out for. Funding one for the uninsured in a time of potential crisis (or all the time) makes a lot of sense.
"But so far it seems it would take a real live nurse or doctor to sort symptoms. Electronic algorithms may just not be sophisticated enough yet."
However, I completely disagree with this. I have a book called "The American Medical Association Guide To Your Family's Symptoms" (the current edition seems to be called "American Medical Association Family Medical Guide, 4th Edition"). You go a page with your symptoms (e.g. Headache) and then it asks you a series of questions via a flowchart to make a diagnosis. You normally end up with one of three results:
1. Go to the Emergency Room NOW.
2. You have ABC and you need to do XYZ about it - sometimes self-treatment, sometimes go to the doctor.
3. You need to see your doctor to make a diagnosis. Sometimes they say immediately if it is more urgent.
To tell you the truth, I'm sure nurses/doctors are doing basically the same thing - it's just that they have it all memorized.
It would be trivial to computerize these flow charts. Then they could be made available to a minimally trained call center. Have the front line people backed by nurses for escalation when necessary.
Additionally, these could be made available via a web site on the Internet. If these exists already, it needs some PR as I've never seen the web site.
I just put post at
http://www.dailykos.com/story/2009/5/24/734885/-Sundays-Alternative-Med…
The Mother Clan, btw in all Cultures that I have done Immersion in for few years, all experience Women where yelling in the desert that sanitation was a must, (Women that where still up, not those depressed and discouraged and then submitted to mysogynists Cultures.
Only Woman Bleed, they discover swiftly the necessity of good hygiene.
Hand washing and how to sneeze and cough in public, in these days and in months ahead it is and will be very important, no Public Health Interventionnists disagree an iota on this.
Prevent Illness - Wash Hands Video
http://www.youtube.com/watch?v=3boxQwSpv-8&feature=related
(Do not forget the Nails)
How to behave when you Dare to Care about others in Public when you sneeze or cough.
Video at http://www.youtube.com/watch?v=Wju7F5ytk6M
Snowy
Charles: Then does it imply it's pointless to quarantine or isolate people who are infected or have close contact with the infected, as in many East Asian countries are doing?
And the only thing we can do is to wash hands more often?
Revere, if you allow me.
Hidy,
Cultures can be so different.
In Tokyo you see in subways people waring mask not to protect themselves but to avoid infecting others.
It is quite consequent then to see that in the Chinese Pandemic Preparedness to included as a mandatory measures that in a declared level 6 by WHO, no one gets in nor no ones get's out.
Cultural differences
Snowy Owl
Just got back from urgent care with my child, who has (as I suspected) strep. Urgent care and pharmacy is full of coughing people who really do look very ill, some with masks. How do I protect my child, who already has strep, from getting something else there? What kind of crazed parent would bring a healthy child into this?
Am I overreacting to sanitize his hands 3 times during the course of the visit, and change his clothes and wash his hands to the elbows when he gets home? I also took a shower.
Salutations Jow,
You do not overreact, but you must now remember as we know that children are antennas tuned to our frequencies.., you did what you have to do, now, be confident, follow the treatment and calm down via Deep Breathing, the child will be essily at ease, you know that.
Be calm, do what you have to do and everything should be the best as possible.
From a single parent of young Twin.
Snowy
Via Crofsblog
at http://crofsblogs.typepad.com/h5n1/2009/05/a-virologist-takes-issue-wit…
May 23, 2009
A virologist takes issue with WHO
Dr. Vincent Racaniello's virology blog is a good place to find clear writing about a difficult subject. Today, Dr. Racaniello is unhappy about the idea that WHO will redefine pandemic. end quote
I then go the the doc website at
http://www.virology.ws/2009/05/23/who-will-redefine-pandemic/
I then read the very first paragraph and I here replicate the first paragraph
The World Health Organization, whose duties include directing and coordinating authority for health within the United Nations system, will soon be writing science textbooks.
I stop reading right there when he Wrote,
coordinating authority for health within the United Nations system.. end quote
This sentence is like a declaration of war between Science and Cultures, many will watch this,
once... an event
twice... a pattern
thrice a program.
It is Eloquent that this simple sentence reveals the colonialism of some academics, ignorant of Cultural Differences and of Powers and Authorities.
If that is a Trend where bound for Burning Hell.
Snowy Owl
GeorgeT: Interesting. I inferred the algorithms weren't there yet because the WebMD interface seems to only add possibilities based on additional symptoms/questions, not take them away. So the more information you provide, the more possibilities are returned.
Whereas a medical professional would be more likely to say, this cluster of symptoms matches this profile. Or, adding symptom Y to symptom X makes diagnosis Z less likely.
That's a "global" versus "local" issue.
On the global scale, containment is a lost cause from the git-go. Unless you are both willing and able to shut down the commercial passenger airline business.
On the local scale, slowing the spread helps because your local facilities are going to be flooded badly enough as it is. You do not want everybody contracting this at once.
Isolation of known or very highly probable cases may help do this.
But people self-isolating when they consider themselves ill, and avoiding large face-face gatherings during a period of high local spread, per policy, is going to help a lot more. So will secondary mitigations such as pneumovax. Pneumovax isn't going to slow the rate of new infections, but it may reduce the severity in some of the people who do get hit.
An argument for school closings when local cases are ramping up is very hard to resist, for the same reasons. Plus a fact that the Reveres have had personal experience with recently: kid goes to school, picks up bug, brings it home and infects the parents.
Schools are amplifiers of contagious disease for the same reason that barracks are.
Reveres:
People might be less likely to go to the ER if they had a better grip on the total number of symptomatic infections. News accounts typically say something like "12,022 cases of swine flu, including 86 deaths, had been reported to the World Health Organization from 43 countries." (NYT 5/23). True enough. But the number of symptomatic infections is way higher than that. (By a factor of 100(?) 1000(?)--I'd really like your opinion on that).
It's easy to see how a parent might think "Yikes, my kid might have a rare disease that everyone is worried about--I better get this checked out." But it they understood better that the illness isn't really so rare or deadly, they might be less likely to jump the gun.
I think this is the biggest failing so far on the public communications front.
As an ED physician I am seeing a lot of the worried well. They typically gum up the ER and then complain bitterly of the 3-6 hour wait to be told that their mother was right...go home, rest and eat chicken noodle soup. This is why we will never, ever have national health care-unless we all under go a frontal lobotomy. Unlike the Canadians, Europeans and British, we dont want to wait, we want everything done and we want it done now. National health will bring a degradation in the standard of care and rationing--the US population accepting that? No way Jose. I would like to see the govt start running public health announcements on the TV, radio etc to educate the public because most schools barely teach health education and common sense anymore and people need to be told you dont need to go to the ER for a hang nail and that a sniffle is sometimes a life event (natural physiologic function).