Influenza

I cannot believe how insanely busy things have been since December. The influenza (and especially H1N1) epidemic has been horrible. I got my first H1N1 patient in early December, a 40-year-old woman with no history aside from smoking 2 packs of cigarettes a day who came in with full-blown ARDS and hypoxia.  She said both she and her husband had flu symptoms, but while he recovered, she did not, and ended up being hospitalized at a small country hospital for presumed pneumonia that did not respond to antibiotics. She got transferred to our hospital when it was clear she wasn't getting better. When I presented her to the pulmonologist, describing her symptoms (high fever, shortness of breath, some hemoptysis), he shook his head and said, "That's classic (for H1N1)." When I asked my patient if she would consent to being intubated, she gave me the thumbs-up, then proceeded to spend the next 10+ days on a ventilator. Fortunately, she was one of the lucky ones, and she was able to go home on Christmas Eve.

Another of my patients, a 68 year old man who was still climbing on roofs working as a carpenter, came to the hospital c/o a 1 week history of cough, fever, sore throat and generalized aches. Because he only had hyperlipidemia, we initially treated him for community acquired pneumonia. The next day, I walked into his room and said, "Hello, Mr. ___, how are you doing---whoa!" The reason for the exclamation? There was a LARGE hunk of bloody mucus sitting in a basin that he'd been spitting into. With my other H1N1 patient fresh on my mind, I called pulm immediately. Sure enough, he had H1N1, and he ended up on a Rotaprone bed for at least a week. Eventually, however, he recovered, though he's now so debilitated, both physically and mentally, that he got discharged to a nursing home after a 1 month hospitalization. Of course, it could have been worse. He could have died.

Fever. Cough. Hypoxia. Hemoptysis. "Fluffy" chest X-ray. Anytime I see 3 or more of these characteristics in the same patient, I immediately think H1N1 until proven otherwise. And even then, sometimes the H1N1 PCR is negative. Doesn't matter; if it acts like H1N1, we treat it like H1N1. I had two patients who tested negative for H1N1 but had the classic presentation. Both were spared intubation, fortunately; one guy recovered enough to go home after a week, while another remains in the hospital 3 weeks later on high F1O2. It's amazing how the same virus affects different people in different ways. When I walked through the ICU, I was struck by how young some of the intubated patients were. One thing they had in common: they didn't get their flu shot this year.

In our hospital, most of our sickest patients were women in their 30s-60s, often overweight, diabetic, or worse, pregnant. We've had 3 pregnant H1N1 patients come through our ICU. The first was a 30-year-old who denied being pregnant on 2 separate occasions; only after she was intubated did her family inform us that she was, in fact, pregnant. A stat ultrasound showed she was 31 weeks along, and because she was so unstable (and on a Rotaprone to boot), her ICU room was turned into a makeshift OR and she had an emergency C-section. Her baby survived, though she did not; she was transferred to another hospital on ECMO several days later and ended up dying. The second pregnant patient was only about 25 weeks along; they put her on ECMO and got to the other hospital, don't know how she did. The third, a woman in her 40s and 25 weeks pregnant with her 5th child, initially got admitted for DKA but almost immediately became septic while in the ED. The baby was delivered via emergent C-section but did not survive. The patient lasted about 3-4 days maxed on 5 pressors before she, too, succumbed. The last case in particular was very tragic, as the H1N1 hit that poor woman hard and fast, and her family lost both her and her child.

The news recently something along the lines of how 9 people so far have died of the flu in our city alone this year; I think the number is probably much greater. Even the pulmonologists said that this winter has been the worst H1N1 they'd seen, even worse than 2009. As a result, our hospital beds are almost always full, there's almost never room in the ICU and IMC because so many people are on the vent, and the doctors are overworked and overwhelmed. Me included.

One of these days, I got to start taking care of me. Otherwise, I don't know how long I can keep doing this.