Last year's flu season was a nasty one and this year's is just getting started. In my emergency department, we've begun to see a trickle of cases that is almost certain to herald an incoming surge. So brace yourselves, winter is coming.
If you're experiencing flu symptoms (fever, chills, cough, sore throat, body aches, malaise, headache, vomiting and/or diarrhea), supportive care and time are unfortunately the only true avenues for relief (more on this later). Hopefully, you have an ample supply of Tylenol, tea, ginger ale and chicken soup. For the rest of you - flu vaccinated or just lucky - I want to set the record straight on some common flu misconceptions.
In a social media post last flu season, my colleague Dr. Kim Sue (Massachusetts General Hospital, Internal Medicine) jokingly captured the frustration we feel as providers:
For providers, it often feels as though we are repeating ourselves year after year, answering the same questions and trying to quash the same misinformation. As a physician, I respect patient's autonomy to choose whether or not to get the flu vaccine each year. But what is equally important to me is that they make this choice based on sound information and also realize that this choice affects others in a meaningful way, including some of the most vulnerable among us.
1. I have the flu.
As it turns out, not all illnesses that make you feel terrible are the flu. There are many potential causes of why we inevitably find ourselves under 5 blankets with a box of tissues, a mug of tea, the entire contents of our medicine cabinet and a long Netflix queue at least once every winter. These include rhinovirus (the common cold), coronavirus, respiratory syncytial virus (RSV), adenovirus, and parainfluenza among others. Less commonly, this same set of symptoms can also be a harbinger of other more ominous diagnoses such as meningitis or appendicitis. If you're ill enough to come to the hospital, we can run a pretty accurate PCR swab to confirm a case of influenza, but this ends up happening in a minority of cases. If you are feeling better within 1-2 days and you don't spike a true fever (>101.4˚ F), it probably wasn't the flu.
2. The flu shot doesn't work.
The effectiveness of flu vaccination over the last several years has varied from 19-60%. This reality becomes easily warped into the myth that the shot doesn’t work at all. The truth is that the flu is a virus with numerous strains and a high rate of mutations which makes vaccine design a tricky business. Somewhere off in a lab each year, very smart people are thoughtfully making an educated estimate of the impending flu strains, several months in advance. And it simply is not possible to do this with 100% accuracy. By the time the vaccine has been manufactured and disseminated we can only wait and see how effective it will be for a given season. So yes, it is possible, as some patients will tell me that “I got the flu shot last year but I still got the flu". But that doesn’t negate the other truth that it saved lives, decreased illness and hospitalization and protected unvaccinated patients via partial herd immunity.
3. The flu shot gave me the flu.
Typically, patients receive a trivalent or quadrivalent (3 or 4-strain) flu vaccination which can be grown via egg-culture, cell-culture or recombinant techniques or, less commonly, a live-attenuated intranasal vaccine. The bottom line is that all forms of the vaccine contain inactivated virus (traditional), weakened virus (intranasal) or simply parts of the flu virus (recombinant), none of which is capable of actually giving you the flu. Yes, you can get 1-2 days of malaise, fatigue, low grade fever and muscle aches after getting the vaccine, which is part of your body's normal immune response. Overall, the vaccine is well-tolerated and serious adverse events are very rare (much rarer than serious complications of the flu). Those couple of days of feeling run down are nothing compared to 3-7 days of debilitating symptoms with up to 2 weeks total recovery time for uncomplicated flu cases.
4. There's a cure for the flu.
Yes, there is an antiviral medication out there that has some degree of activity against the flu virus. It’s called olsetamivir, but more commonly recognized by its trade name Tamiflu (the other FDA-approved antiviral is zanamivir or Relenza). It is true that it does something and the CDC does recommend that physicians “consider” administering it to flu patients in general and give it to high-risk patients. Overall, the available evidence* around Tamiflu, which was largely funded by industry, suggests that when given early in the flu course (in the initial 24-48 hours) that tamiflu decreases the duration of symptoms by less than one day. And it is not without risk of side effects, including increased incidence of confusion and psychiatric events, headache and nausea/vomiting. Turns out that there is an effective treatment that cuts flu symptoms to zero days! The flu shot! No, it’s not perfect but it’s quite a bit more perfect than Tamiflu.
Of note, there is also a new, single-dose flu medication, called baloxavir (Xofluza) that was just approved by the FDA this October. The new drug was approved based on two clinical trials which showed a faster recovery time versus placebo, specifically about 23-28 hours. It isn't clearly better than Tamiflu, but the jury is still out on how it will perform in the general population.
*Despite being FDA approved in 1999, it wasn't until 2014 that all clinical trial data was made fully available. For much of this period, despite significant national spending on Tamiflu, much of the data remained unpublished or selectively published by Roche Pharmaceuticals.
5. It's just the flu.
Although the exact number of flu related fatalities is difficult to calculate, the CDC estimates that during the period from 2010 to 2015, annual flu-related deaths ranged from 12,000 to 56,000. Last year, it was over 80,000! An estimated 90 percent of deaths occurred in patients over 65 years old. Many of these patients died of complications of the flu, such as pneumonia, and had other co-morbid conditions that put them at higher risk. Young children, older adults (>65), pregnant women and those with asthma, COPD, heart disease and other conditions have a higher mortality risk. Yet each flu season, there are also fatalities among otherwise healthy children and adults.
Also important to realize is that it may be 'just the flu' for most healthy patients, but it can also affect more vulnerable populations. The flu vaccinated patient has a decreased chance of contracting the flu (though non-zero) and if they never get sick then they never expose others. The non-vaccinated patient who does get sick continues to spread the flu virus potentially to the elderly, small children, asthmatics and other groups in which flu mortality is higher.
I will never tire of giving a (educational) rant on the topic of vaccination and public health. I hope that in some small way this post can help fend off the onslaught of misinformation that troubles the internet and help contribute to reasoned discourse and scientific understanding on this topic.
Feel better, America!
When I was growing up, there were two things that I wanted to be more than anything: a doctor and a writer. Before I pursued medical training, my very first dream was to be a novelist. My childhood journals and old home computer were always littered with story ideas and the beginnings of novels. Even as I prepared for a career in medicine, I also maintained my love of storytelling and writing. I majored in American History & Literature while doing my pre-med classes, I pursued a journalism degree prior to going on to medical school and I started working as a freelance writer. When I began residency in Emergency Medicine in 2015, I knew that writing would have to take a backseat as I completed my clinical training, but it's also something I've missed a great deal over these past few years.
That is why I’m so excited to share my new essay, "Exposed," which appears in the latest issue of Annals of Emergency Medicine. I’m grateful for the opportunity to join these two passions, to take an experience in medical training that was challenging and formative and share it with others in my specialty through creative writing.
This essay centers on an experience that I hope will resonate with other healthcare providers: the dreaded needlestick injury. The piece examines the constant threat of the unknown that all clinicians come to know well, a fear that also helps keep us sharp and ready for anything that comes through the door. I attempt to capture how this anxiety and uncertainty mix with the thrill of discovery and capability during medical training. The lesson for me was that such an experience reveals an inherent truth of our field: the risks and rewards of medical practice are inextricably linked.
You can read my essay, “Exposed” for free until September 7, 2018 here:
Thanks for reading!
Thanks so much to all my friends and colleagues for voting for my submission to the 2018 Essentials of EM - Academic Life in EM Visual Design Competition. Congratulations to the winners, Dr. Liz Fierro and Dr. Natasha Li from Loma Linda University Health! While my entry was not selected for the grand prize, I was happy to see that it garnered the most views of all the submissions (over 6,000 as of this post). I'm very grateful for the exposure and all the supportive feedback from my EM colleagues.
I am very excited to announce that I have been selected as a semifinalist for the 2018 Academic Life in EM - Essentials of EM Visual Design Competition!
4 semifinalists were selected from submissions in various topics in emergency medicine. My submission was inspired by my recent blog post (see below) and is an infographic on management of calcium-channel blocker overdoses. The winner of the competition is selected for an EM Education Mini-Fellowship and is awarded travel to this year’s EEM Conference in Las Vegas in May 2018 where they support multiple aspects of the conference.
I would greatly appreciate your support! Voting is open to the public until Saturday, January 27 at 8pm. Please feel free to share!
Recently, I took care of my first patient with a major calcium channel blocker (CCB) overdose. He was a middle aged man with unknown past medical history who had reportedly taken 20 tablets of diltiazem 120mg ER in a suicide attempt. Initial blood pressure in the field was 60/32, heart rate 30-40s. Knowing on an abstract level how sick these patients can get is one thing. Seeing it firsthand is something else entirely. Here are some lessons learned from a harrowing toxicological encounter.
Fortunately, this patient did well and ultimately did not need any 'end-of-the-line' therapies. This was a challenging yet valuable first brush with one of the sickest of all types of overdose patients. Like all difficult cases in the ED, teamwork and good communication were the bedrock of successfully managing the overdose.
In the emergency department, we deal with a large volume of sick patients. Not only are many acutely ill, but they are often undifferentiated. Our daily lives include encounters with sepsis, STEMI, and shock and no shortage of other surprises. As a result, we develop a certain level of comfort with these high-stress situations.
Yet there are some encounters that move beyond even the daily ebb and flow of high acuity. These are the scenarios that make us break out in a cold sweat as the CMED call comes in. The ones that can form a knot in our stomachs even days or years later. Every clinician has cases like these that are seared into their memory, cases that help us grow as doctors.
We sometimes refer to such patients as 'sick as stink' (SAS) - or even use a slightly more colorful version of the phrase. Though couched in the typical irreverence of the ED, this reference is not used in a derogatory manner. In fact, the expression is one of humility for the ways in which medicine can always continue to surprise and challenge us. It communicates a necessity for vigilance to our colleagues. It is an admission of how much a case affects us. These are the patients whose faces we can conjure effortlessly, who will become a symbol of what we learned, the unforgettable cases.
SAS will be a recurring column on this site, a collection of my most memorable cases (de-identified as always). They will be mainly educational (rather than esoteric), meant to consolidate and share what I learned from these high stress encounters. I hope you enjoy the first installment!
SAS - Episode 1
As I near the halfway point of my third year as an emergency medicine resident, I've been inspired to shake the cobwebs and dust out of the right side of my brain and start writing again. In a previous life, I was a journalist and research writer, but after four long years of medical school and about two-thirds of my residency, that person started to feel a little foreign to me. After finally completing a long-term research project and experiencing the pride of seeing it in print, I began to long for the different but just as powerful feeling of crafting writing born of creativity and imagination rather than spreadsheets and statistics. Starting with the clinical training of my third year of medical school, I've had less and less time for these activities. But I promised myself when I started out at medical school that this part of me would not disappear, that even if it went into a period of hibernation, I would bring it back to light. Now I finally feel that a cloud has started to lift. As the scaffolding of emergency medicine becomes sturdier (though certainly not yet complete), there seems to be space for this other, equally important side of myself.
The goals of this site will be severalfold and I'll attempt to outline them now to give myself a framework moving forward.
And with that, I'd like to re-inaugerate joshuacolin.com. For all of us, clinical practice is just one facet of our lives. I hope that this site will serve as a new outlet for me, to inspire creativity, learning and excellence in clinical practice in both myself and others. Thanks for visiting and enjoy!
1. "We have to remove the bullet!"
Despite the harrowing scenes this trope creates, this one drives me crazy. A character is shot, oftentimes in the abdomen, and ultimately undergoes a painful extraction of the bullet fragment (whenever suits the plot). Sweat drips from the surgeon's face as he pulls it out, usually with the help of some liquor as an antiseptic, the patient screaming or perhaps gritting their teeth stoically. And with a few hours of rest, that same character is ready to go like nothing even happened (though he or she is obligated to wince from time to time just to remind the viewer). As it turns out, you can still bleed to death from a vascular injury (in seconds) or liver laceration (in minutes to hours) or die a horrible painful death from a perforated bowel and sepsis (in hours to days). Taking the bullet out fixes none of these problems and has a reasonable chance of making things worse. After learning the anatomy and running real-life penetrating traumas, these scenes just demand too much suspension of disbelief.
It's true that we do say "clear" in the emergency department, though perhaps not as often as on ER or House. This inaccuracy lies more in the delivery. First of all, this doesn't happen nearly as often (which is good because it means someone is on the brink of death). And though it's often a tense moment, this phrase is about communication, not drama. More often, you're going to hear something like, "I'm clear, you're clear, everyone's clear," in a measured voice. Charging in with the paddles defeats the purpose, as 'clear' is about keeping everyone else safe from the electrical shock being delivered to the patient.
3. "We've placed him in an induced coma."
The concept of a coma is tremendously misunderstood, and television shares at least some of the blame. The term is used carelessly and imprecisely (with tragic consequences) for other types of conditions, such as persistent vegetative state and brain death, from which people do not recover. Some people, for example, those with traumatic brain injury (TBI), do recover and eventually "wake up". But sadly many with severe underlying brain injury will never wake up. And this television inaccuracy creates false hope that creates suffering for patients and families and a huge burden on the healthcare system.
Pretty much everything in the emergency department is stat (especially in comparison with the rest of the hospital) so it's really not necessary to say it out loud, much less shout it. If you tell a seasoned ED nurse that something is STAT, you are guaranteed to get an eye roll as they go back to whatever they were doing. The only folks I know who still say stat without a hint of irony are neurosurgeons, and they are in a class of their own. After all, it literally is brain surgery.
5. "He's flatlining! Charging... clear!"
Sorry, this one is just wrong. Delivering an electronic shock via defibrillator is a method of converting someone from a non-perfusing, disorganized rhythm (ventricular tachycardia or ventricular fibrillation) and resetting their heart to a normal sinus rhythm. You cannot shock someone out of asystole or pulseless electrical activity because there is nothing to reset. All you can do is continue CPR, push epinephrine, and think about reversible causes (and cross your fingers). Put the paddles down, doctor. And speaking of which....
6. Those paddles
Maybe this one isn't so much of an inaccuracy as it is outdated. The television show ER was my first introduction into the field of emergency medicine. And, while I definitely didn't mention this in my residency interviews, at least some small percentage of my choice of speciality came directly from watching it. Gosh darn it, I just want to use those paddles one time, is that too much to ask?! But alas, as it turns out its safer and quicker to apply defibrillation through large sticky pads. Less badass, unfortunately, but in the end better for our patients and safer for the ED team.
7. Successful Resuscitation
Unfortunately, television shows and movies drastically overstate the success of resuscitation. If a patient becomes so ill that their heart stops, there are often forces at work that are irreversible, even with the very best medical care and high quality cardiopulmonary resuscitation (CPR). This is especially true in cardiac arrest due to causes like blunt trauma (e.g. a car accident), advanced infection or cancer. Successful resuscitation is more likely in situations such as respiratory arrest leading to cardiac arrest or in penetrating trauma, such as a stab wound, in which there is an isolated injury that can be temporized and then corrected surgically. But even in scenarios with better odds, the rate of survival is still quite low, at best about 1 in 3 and at worst about 1 in 100. The numbers are much worse when you exclude patients that suffer neurological injury even if their bodies survive. The television portrayal of CPR was even the subject of a 1996 New England Journal of Medicine article (https://www.nejm.org/doi/full/10.1056/NEJM199606133342406) which catalogued medical television dramas and found that 75% of patients depicted were resuscitated and 67% left the hospital alive. Sadly, this just isn’t the case.
8. Getting McSteamy
I'm sure it does happen from time to time, but certainly not with the frequency portrayed on television. Though emotions can run high in the hospital setting, it is still our office. Plus the stained mattresses of shared call rooms, crowded supply closets and the blood, urine and vomit of the work day aren't exactly aphrodisiacs. That's not to say that relationships don't catch their spark and blossom in the hospital, they certainly do. But the rest is better left for the bedroom, rather than the supply closet.
9. "He's seizing!"
Seizures tend to be a very misunderstood condition as well. They look very dramatic and this causes others to respond in dramatic fashion. The disconnect here has always bothered me. Even in this hospital setting, seizures tend to receive outsized attention. A patient who experiences a seizure that stops after a few minutes is almost certainly going to be fine. In contrast, someone with cardiac chest pain and EKG abnormalities has a very real chance of dying any minute even though they are awake and talking to you. Television has certainly contributed to some of the problematic treatment of seizures as well. Specifically 1) trying to restrain a seizing patient and 2) trying to put something in the patients mouth. In reality, these are the last things you should do. What someone should do if they witness a seizure is make sure that they patient is an a position and location where they are at minimal risk of harming themselves.
10. Organ donation
Last but not least: organ donation! Donation of organs after death is also a very misunderstood area that is perpetuated by depictions on television. In reality, donation is a very rigorous process that requires specific guidelines and permission in order to move forward. In particular cases, including donation of heart or lungs, which can only come from a brain-dead donor, this involves even further stringent medical testing to confirm brain death. Things that NEVER, EVER happen include 1) deciding whether to resuscitate someone based on their donor status, 2) deciding whether to ‘pull the plug’ based on their donor status, 3) reserving an organ for a specific person from a deceased or brain-dead donor. If you’ve ever come across these misconceptions, I encourage you to learn more about organ donation and become a donor yourself (organdonor.gov).
Joshua Feblowitz, MD, MS, is currently a PGY4 resident in the BWH/MGH Harvard-Affiliated Emergency Medicine Residency (HAEMR) Program and a freelance science writer.