to getting ready:

I guess I can't imagine not taking care of flu patinets.   Prioritizing non-infectious disease over infectious disease seems unfair. It's also impractical. I have seen computer models wherein the disease spreads from a single case in LA to 300 cases per 1000 population here in Pennsylvania within 6 weeks. With that many cases, you can figure that a percent of the trauma cases, heart attacks and everyone else who needs hospitalization would be either sick, or recently exposed and not yet showing symptoms.

As you suggested, there will be community based triage centers and maybe even some high school gymnasiums turned into low level treatment centers where on-the -spot trained people can give IV fluids to dehydrated people and care for flu patients who have no local family.   

What is truly needed is local and community organizations that will allow groups to pool resources and manpower. Community organizations that distribute food and check in on people who live alone may save more than the most advanced medicine. I just hope that people aren't so afraid of each other that they can't help each other.

to gghugs:

I don't know what to say about the frustration of interacting with individual health care providers except I'm sorry. Unfortunately, the same variation in level of concern and education about BF that you all see in your peers and colleagues exists among physicians and nurses as well. The same denial of that which is too scary to contemplate affects us too. Remarkably, to my knowledge there has been no official communication to private physicians from the government or any other health agency about bird flu.

I suspect that those of us who are sensitized about the issue are either slightly paranoic, like everyone else here (I say this affectionately, and I include myself) or informed by the hospital they work for. My colleagues in the ICU are intellgent, informed people who have grown tired of listening to me and joke that they'll show up at my house if anything hapens. Sound familiar? I'm still not sure if we (on the forum) are all unusually clear sighted or unusually paranoid. Of course, just because you are paranoid doesn't mean the threat isn't real.

It is this variation in awareness that leads some docs to refuse to give extra supplies of usual meds. There has been no clear official announcement that would trickle down to all physicians urging us to do this. I suspect that the doctors who refuse do so because they simply don't recognize the need. If the medcine in question is a controlled substance, nobody's going to give out a longer supply.

Try printing out information from CDC suggesting stockpiling meds and show it to your doctor. If this continues to be a problem for people, I suggest that people on this site organize a letter and petition to the CDC and AMA, and AAP to advise outpatient physcicians to comply withh this reccomendation of the CDC. I'll help if necessary. Many peoples lives may depend on it.

Could someone who reads this set up a poll to determine whether people are getting the extra supplies of current medications that they need from their docs? I don't know how. That way we could decide how aggressive to be.

I have to add that I wouldn't support passing out antibiotics or things like phgenergan either. Phenergan has tons of side effects! So far the secondary infection rate in H5N1 is low. I know it was high in 1918. It may be that H5N1 patients aren't living long enough to get infections. We'll know more as the disease evolves. If you get a secondary infection with pandemic flu, you probably need tot be hospitalized to get IV antibiotics. Taking antibiotics prophylactically will only give you diarrhea and select out resistant organisms.

I don't understand why anyone would be denied pnuemovax. I'm not saying those docs are crazy, just that I don't understand their reason. But then, I don't do outpatient medicine.   

I don't have the vaccine myself.

take care,
the gardener

    

   gardener I think the thing that Pebbles does not understand and what you just mentioned above is that low tech minor interventions will save far far more patients than big time high tech ICU interventions. In Philadelphia in 1918  500,000 persons were infected with flu at one time and 40,000 died. Statistically only about 10,000 should have died. I feel most of these deaths occurred because everyone was sick and there was no one available to give even basic care. In a triage situation you and I are forced to allocate scarce resources in a way that brings the most benefit overall even if it is to the negative benefit of some persons. One of the ways we plan to decrease the size of the box we have to build is to block the sending of  nursing home patients to the ER because of reasons I listed in the hosppital preparations section of this web site.   ER doc

   Yes, every physician in the state of Texas was sent this week the Texas Medical Board Bulletin. In this was an article Be Prepared for Pandemic Flu. This article discussed pandemics in general and H5N1 in particular. SARS was discussed in the context of how this relatively small "epidemic" in Toronto put hospitals at surge capacity, while shutting down schools and churches, causing widespread hysteria. Also listed were informational web sites. This included www.pandemicflu.gov/  and www.pandemicflu.gov/plan/tab6html and www.dshs.state.tx.us/preparedness/pandemicflu/professionals/   . "Information available to health care practitioners includes tool kits for medical offices and clinics to develop an influenza plan."  The article concluded "Have a business continuity plan."   ER Doc   of note I will be going to my father's ranch to help him work cattle for the next few days and will not be posting

    jo007athome

I sympathize with both sides on this. note that the following is not inteded to be a substitute for advice from a physician who is seeing the patient.

simple things first. ARDS is a vague term that describes a level of respiratory failure. It has many causes, infectious and non-infectious. It's a clinical syndrome (a bunch of symptoms that ooccur together) rather than a discreet disease entity that has a specific treatment.   

You won't wonder if someone has ARDS. They will have trouble breathing, and they will tell you that they need help. They will breath fast and hard and you will see the muscles between their ribs suck in with each breath. They will look scared. Try to come to a hospital before they turn blue. Eventually they will go from alert and scared to confused and sleepy. At that point they are close to death. People don't survive ARDS without medical care and really without mechanical ventillation.

It isn't that hard to treat a flu patient at home, because there isn't much you can do. The pneumonia is viral. there's nothing you can give to make it go away, except maybe tamiflu if you have it, and that only within the first 48 hours. After that it probably doesn't do much. There's nothing you can do to fix it. Either it will get so bad that they need help breathing or it wont. (Recent review of patients treated up to now showed a low incidence of secondary infection.) In the meantime, keep them comfortable and well hydrated. Control fevers as you can for comfort, to prevent fluid loss, and to prevent seizures in children.

Keeping flu patients well hydrated and recognizing when they need help breathing is the most important thing you can do for them. Getting significantly dehydrated will predispose you and to ARDS to multiple organ failure.

Other than hydration, there is nothing you can do to prevent multiple organ failure. If it is going to happen, it will happen.   Unfortunately, we wouldn't be doing anything diffferently in the hospital. We won't give them a lot of medicines.

What we can do in the hospital that you really can't do at home is give them help breathing if they need it.   I don't just mean ventillators, which will be in short supply. Oxygen alone will probably save a great many. God help our oxygen delivery system. We can also give patients IV fluids if they can't stay hydrated by mouth.

If they get secondary infections, we can treat them. We won't necessarily assume they have a secondary infection until we see signs of it. What are these signs?   It's hard to say, exactly . Its things like getting worse when you thin they should be getting better, or getting better and then getting sicker again.   In the hospital I would would look at thhings like white blood counts going up, platelets falling, x-ray changes or positive cultures, but of course you can't at home.

Until we understand the time course of the disease in detail, the information I have just given you is useless. We need experience with the virus that becomes pandemic before we can say much more. It's hard to generalize abbout this flu, because in many ways it is different than anyting we have ever seen.   There isnt even detailed information available to determine this about H5N1 as it now exists in Asia.

In reality, because this virus is associated with such profound immune supppression, if you get a secondary bacterial infection you need to be evaluated by a physician. Bacterial infections in immune supressed patients can become fatal unelievably fast.

It is hard for an untrained eye to apreciate the subtle signs of a patient who is about to go downhill. I struggle to teach the residents (who have been to medical school and have 1-3 yearsof post-med school experience) these signs. it's just not that simple. It is , in my opinion, impossible to distill the distinction between "must go to hospital" sick and "OK to stay at home" sick into simple numbers.

That said, you would be well served to learn the normal vital signs (by age) for the people in your family. Learn to count heart rate and respiratory rate. Learn to test blood pressure. Take seriously a fast respiratory rate and a fast heart rate (in a calm adult or a child who is not screaming) that persists after a fever is brought down. Both warrant evaluation by a doctor. Low blood pressure should prompt you to go to the ER, fast. Low blood pressure is a late and ominous sig: the patient should have been seen before that happpens. Learn the signs of dehydration like fast heart rate, sunken eyes, absent tears and dark scant urine. For more on that, go to rehydrate.org, a website designed to teach everyone, even the siblings of dehydrated children to recognize and treat dehydration.   

Unfortunately, and at the risk of sounding arrogant, you won't be able to learn how to diagnose and treat problems much more serious than you usually treat at home. In my opinion the most valuable thing to learn is when you are over your head. I have heard others, particularly Montana survivalist types reccommend a book called "where there is no doctor." I have never seen it, so I can't comment on how good it is. Those folks are serious about disaster preparedness, so I bet it's good.

About antibiotics:

No one can tell you which drug to use to treat pneumonia, because it is caused by many different things. Streptococcus pneumoniae is by far the most common cause of pneumonia. I assume it still is in the era of pneumovax, but I'm not sure. We might see new information in a few years. It was a very common cause of infection in the 1918 pandemic. First generation cephalosporins (which are related to penicillins) usually treat it, but not always. You might ask Frisky what he uses in the ER as a first line outpatient drug for community-acquired pneumonia, but understand if he isn't comfortable talking about it due to liability issues. please understand if he isn't comfortable talking about it due to liability issues. For a list of causes of pneumonia, look at this website and or google comon causes of pneumonia.

http://www.kcom.edu/faculty/chamberlain/Website/pnebact.htm

(This is not my university, BTW, it just came up when I googled it)

I hope this list gives you some understanding of your doctor's being reluctant to make blanket statements about what to do. In addition to there being a whole lot of potential causes, each bacterial infection has it's own resistance profile. Not just each type of bacteria. There are probably thousands of different strep pneumo strains each with it's own characterisics. You could say the same of each bacteria.

good luck,

the gardener

gardener wrote:      About antibiotics: You might ask Frisky what he uses in the ER as a first line outpatient drug for community-acquired pneumonia, but understand if he isn't comfortable talking about it due to liability issues. please understand if he isn't comfortable talking about it due to liability issues. http://www.kcom.edu/faculty/chamberlain/Website/pnebact.htm the gardener

    http://www.avianflutalk.com/forum_posts.asp?TID=2604&KW=&PID=30380#30380

Er

Thanks Gardener, for the valuable insight . One of the most frustrating things we are dealing with here is not having an SOP for this bug. Ugh, I re-read my post  this A.M and I am sorry that I sounded so rough, generally I am a nice person. I guess we will just do the best that we can with the knowledge we have at that point. Maybe we will get some more info on this awful bug before it becomes pandemic. I do wish that laymen could get more info, as I foresee  them being the primary caregivers when this gets here. I for one won't be going to the hospital with my ill, hospitals will be overtaxed and if you aren't sick when you take someone there you probably will be from extreme exposure, even now hospitals are a good place to stay away from. I got out of the medical field because I catch everything that goes around and I don't like being sick. I subscribe to the NEJM and watch diligently for anything that could be helpful. I am very, very grateful for the information you offer and I hope you will stay with us. The people who are preparing will be the ones who will be helping those who haven't and the better off we are, the more help we'll be able to provide.  If this doesn't hold true, then society will be doomed.

Hey all,

on another thread [gaiming immunity] Jhetta put up a link to a powerpoint presentaion from one of the docs who toook care of the 1997 hong hong epidemic. It's only 18 patients, but It is the most thorough description of H5N1 infection I have seen yet.   It is possible that things are a little different now (the mortality is certianly higher this year.)

The thing that stood out in the slide presentation to me are the really weird causative organisms for secondary infections.   Acinetobacter, stenotrophomonas, pseudomonas, MRSA and proteus. that's freaky! it's definitely not following the usual influenza rules. Keflex isn't going to do you much good if that is representative. This list of unusual (and traditionally hospital acquired) organisms tells me that you can't predict what you would need.   Maybe the only reason that infectious agent are so strange is that they gave prophylactic antibiotics to usual things, like staph and strep, leaving these bugs behind. who knows. Obviously we need more info.

pugmom-- I had to wrestle with the surgical residents too, and I'm an attending in the same university hospital ranked in the top 20 hospitals in the country. Surgeons usually think pediatricians are idiots, but my partner, who is a surgeon, was also present. It was surreal. It's hard to imagine what it's like getting medical care without a clinician in the family.

gardener

  Hi Pugmom, I love your name.  How did you come up with it?  Anyway I would like to have some antibiotics on hand just in case.  If you don't mine telling me, will you give me the name of the pharmacy you used on the internet.  Do I need a Rx for these medicines?  Any help you can give me would be appreciated.  Thanks a lot

Hi MM--I have 6 pugs.  I also run a pug rescue, but am thinking about dissolving it, as we are incapable of bringing them back to health and then adopting them out.  We fall in love with all of them.  In answer to your questions, I already erased the pharmacies I used to get the antibiotics.  I used a veterinary supply company in California for 2 of them, the Doxy and the Keflex.  (Pharmacy-grade drugs and you don't need an Rx.)  For the Bactrim, I went to a pharmacy supplier in Canada that used a foreign manufacturer.  They have you fill out a quick questionnaire to be reviewed by their pharmacist.  I have ordered overseas before for my Tamiflu, a one years supply of blood pressure meds, etc. and they have all come and are in original packaging, etc.  There are warnings all over the place about how the consumer must be savvy, as there can be fraud out there.  I researched alot of the companies and compared, and in the final analysis, just bit my tongue and hoped for the best.  Fortunately, I have not been scammed.  I think I Goggled something like:  online pharmacy Bactrim.  Or something like that.  For the Doxycyline and the Keflex, I just googled those names.  Noone seemed to carry them but the Veterinary supply outlet in (northern, I believe) California.   Gosh, I wish you good luck, the whole search was kinda exhausting and I was so relieved when they all finally came.  I just erased those out of my address book yesterday, wouldn't you know it.  I am sorry I can't remember to tell you more.  Just Google either "online pharmacy Canada Bactrim', or the drug's names, like "bactrim, " or "veterinary supply Keflex."  I guess you get the idea.  Hold on now, MM, I decided the smart thing to do was go look at my pills!  The Doxy and the Keflex are made here in the US by Thomas laboratories at www.THOMASLABS.COM.  I can't remember the name of the California supplier.  The Bactrim (it was really hard to find--no place here in the US)--I got it from XLPharmacy.com (from Canada.)  It is the double strength Bactrim (DS) and is 160/800mg.  This should help you more.  Good luck!