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Flu Fears: Top 5 Misconceptions About Influenza

11/8/2018

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PictureCredit: MedicalGraphics.de, license CC BY-ND 4.0
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:

Patient: “Aren’t people dying from getting flu shots this year? That’s what I heard.”
Me: “From your doctor (i.e. me)? People are dying from not getting it. Getting intubated.
​Let me jam this vaccine into your arm with the force if my accumulated anger hearing these ongoing misconceptions.”

Patient: “Fine, you always make me get it every year anyway.”
Me: “Good for me for having the fortitude to have this conversation with you every year.”
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.
Have you heard of herd immunity? 
I'm not sure that I will ever be able to explain herd immunity to someone who doesn't want to hear it, but that will never stop me from trying. Herd immunity is essentially indirect protection from an infectious disease due to a large portion of the population being immune (either naturally or via vaccination). If immunity covers a sufficient number of people, it indirectly protects people that are non-immune by making it much more difficult for the infection to spread. Breakdown of herd immunity due to lower vaccination rates is what has caused public health crises such as outbreaks of (very preventable) measles. In the case of the flu, the vaccine isn't effective enough to produce complete herd immunity, but we still get some of its beneficial effects including decreased transmission and partial protection of vulnerable populations.
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.
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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.
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Tamiflu: 16.8 hours of flu symptom relief!
*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!
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Thanks for your support!

1/31/2018

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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'm including the full submission in the link below (high resolution png file). Please feel free to download, use and share. Thanks again for all of your support. I look forward to submitting again next year!

Infographic Calcium Channel Blocker Overdose
File Size: 2104 kb
File Type: png
Download File

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Visual Design Competition Semifinalist

1/26/2018

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Infographic: Prescription Calcium Channel Blocker Overdose, A Rapid Review of Medical Management
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.

VOTE HERE

My entry

 
​I would greatly appreciate your support! Voting is open to the public until 
Saturday, January 27 at 8pm. Please feel free to share!
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SAS, Episode 1: Calcium Channel Blocker Overdose

1/4/2018

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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.
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  1. Resist the urge to panic. This was by far one of the sickest patients that I've ever seen. Refractory shock, altered mental status, agitation, erratic blood sugars. When the CMED call comes in, center yourself, run your list and make sure you have the resources you need, because you'll be in that room for the foreseeable future. You'll need a plan for how to cover other acutely ill patients under your care. Keep calm, anticipate possible interventions (and the requisite equipment), and prep your team (especially your primary nurse).
  2. 1-800-222-1222. Speaking of asking for help, the mind of an experienced EM-trained toxicologist is just a phone call away. Although most EM practitioners are comfortable with a tylenol, opioid or benzodiazepine overdose, this is the kind of case where you should have a toxicologist whispering in your ear. There's a great deal happening at once and it's near impossible to step away from the bedside to look up the myriad interventions you'll be pursuing. A poison control consultation can help guide you through a tricky set of treatments and counsel you on the most challenging parts of the case, such as whether to give lipid emulsion therapy or transfer to an ECMO center.
  3. Just put the central line in. ​The situation is almost certainly going to get worse before it gets better, and you need access. You know right out of the gate that you'll be giving: 1) IV calcium in high doses, 2) high-dose vasopressors, 3) large volumes of IV fluid and 4) a multitude of other drugs (see below). Ergo, a central line is practically guaranteed. In my experience, I've been lulled into a universe of easy peripheral access. Our nurses are outstanding at blind PIVs. Need volume? A 14-18g will do the trick. Need pressors? Well, low dose peripheral pressors are ok (for a while). Tough access? Grab the ultrasound machine. But in the sick calcium channel blocker overdose patient you've immediately committed yourself to 4 or more drips (plus high dose pressors and high volume). You're best served by walking into the room with a plan to drop a line (and a kit in your hands).
  4. Do everything. In emergency medicine, we are used to acting quickly based on limited information, but we also tend to want to observe the effect of our interventions prior to pursuing more aggressive ones. This is one clinical scenario in which multiple simultaneous interventions are recommended. These include:
    1. IV crystalloid - bolus 500cc-1L, repeat as needed
    2. ​Atropine - 0.5-1mg IV up to 3mg
    3. IV calcium - 10 to 20mL of 10% calcium chloride over 10 minutes (via central line), repeat up to 4 times every 20 minutes OR 30 to 60 mL of 10% calcium gluconate
    4. Glucagon - 5mg IV bolus, repeat 2 times every 10 minutes up to 15mg total
    5. Vasopressors - Levophed (norepinephrine) is the pressor of choice.
    6. High-dose insulin. And I mean, really, high-dose insulin. Half the battle will be convincing yourself and your staff that it's OK to bolus 100 units of regular insulin IV in a non-diabetic patient. Insulin causes a positive inotropic effect in CCB toxicity and counteracts the refractory hyperglycemia produced in such overdoses. So,
      1. ​If blood sugar is < 150, give D50; replete K;
      2. Bolus 1u/kg regular IV;
      3. Give continuous insulin 0.5/kg/hr IV, max 10u/kg/hr;
      4. Titrate to euglycemia with 5-10% dextrose.
    7. End of the Line. ​If nothing is working, then the following are your final stops in addressing a CCB overdose:
      1. ​​Intralipid (IV lipid emulsion). 1-1.5 mL/kg of 20% lipid emulsion solution. This should be done in consultation with a toxicologist. (An important aside: ​hemodialysis is not effective in these cases)
      2. Transcutaneous / transvenous pacing / aortic balloon pump. Given that these overdoses can produce a refractory mixed shock, you may need to try pacing in some form or get an interventional cardiologist on board.
      3. ECMO. If all else fails, extracorporeal membrane oxygenation is an option, but may require transferring a highly unstable patient to an ECMO center. Additionally, one caveat I learned in the course of caring for this patient, is that you cannot give intralipid and then place them on ECMO as it causes problems with the circuit.
  5. ​Get to the ICU. These patients will be extremely resource intensive for the entire duration of their ED course. In this case, my patient needed one-to-one nursing (often with the help of 1-2 additional nurses) and I was physically in the room for nearly the entire time. It was fortunate that I was in a place and at a time of day where this was possible. But if resources are tight or coverage is light, this patient could quickly tax the department as a whole. The interventions you'll be applying are also numerous and dynamic in nature. This is exactly what the ICU exists for and you should hyper-aware of disposition for these patients. You need to protect your patient and your department by getting them to a high level of care as quickly as possible.

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.
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SAS, Episode 0: The Unforgettable Cases

1/4/2018

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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

​-J
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    Author

    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.

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