Should I Stay Or Should I Go? An emergency physician as an emergency patient… again.

Should I stay or should I go?iStock_000026176395_Medium

That’s the question I faced yesterday as I pondered whether I was sick enough to go to the emergency department for care. Yes, me. The emergency physician. You’d think such questions would be fairly easy, but they are far from such.

I’m sure people outside of my profession find themselves in similar conundrums when deciding whether or not they should seek care emergently or just wait to see if their illness is self-limited, as most are. Self limited means it’s going to get better on its own, so, basically, suck it up cupcake.

But, for those of us who work in the ED, actually venturing through the sliding glass doors as a patient is a little more complicated. We don’t try to make it that way, it just is. As providers, we see all those people who come in for our care in search of some magic therapy that will cure all their ills. As we assess them, our primary goal is to just make sure the afflicted soul doesn’t have some life-threatening malady. In addition, we try to offer them some symptomatic relief, most of which could be attained to a similar degree with over-the-counter medication and some bedrest.

Now, the last time I did a post about my own experience in the patient bed (Wearing the patient gown), I had gone to the hospital for chest pain and EKG changes. That was rather straightforward. No pondering needed.

Yesterday, however, my two days of a summer cold took a rather abrupt change. Driving 2 hours to take the minions to the Children’s Museum, I started off just a bit achy, thought my cold was just getting worse, but nothing bad enough to cancel the trip. Right around noon, I had some increase in the muscle aches (we call that myalgias), and felt like I was starting to run a fever. Also, not the end of the world. We stopped for some Tylenol and ibuprofen to treat the fever and the pain. Even with these wonder drugs, I actually had to leave the museum to lay down in the car while my emergency nurse fiancée weaved the children through dinosaurs and train displays. Still, going to the ED was not on my radar.

As we drove home, my thoughts shifted from, “Wow, I don’t feel well,” to “I bet this is what death feels like…”

I watched my heart rate hover in the 130s on my Apple Watch (yes, I’m an early adopter), even after my fever broke. At home, I laid down, my heart rate still in the 120s, then up to 148 if I stood up. Now, those vital sign changes can occur with fluid loss, such as working out in the heat, or vomiting and diarrhea, but I had none of those insults to my body. My respiratory rate was 22, which is also a bit elevated.

I provide you with all this background to say this. I have an entirely new respect for this entity known as SIRS (Systemic Inflammatory Response Syndrome). SIRS plus a source of infection is sepsis, which essentially means your body is really reacting to whatever infection it’s battling. Since one of my goals is to educate the public, I’ll teach you what the SIRS criteria are. You need 2 of these plus a source of infection to qualify as sepsis. Heart rate > 90, respiratory rate > 20, temperature > 100.4, white blood cell count > 12,000 or < 4,000.

Yet, despite all I know, my abnormal vital signs, and feeling like I had just been pummeled by Tito Ortiz in the octagon, I still debated whether or not I should go to the ED. Riding to the hospital, I wondered if I were overreacting. In the end, it was my rapid heart rate and my belief that some intravenous fluids would help me feel better that convinced me to enter under the sign titled: EMERGENCY.

Once inside, my heart rate did not magically improve (that was honestly my concern, because then I would have been declared a fraud!). My initial labs showed a white blood cell count of 25,000. Most of these were neutrophils, the subset of white blood cells that crank up in the presence of bacterial infection. While my x-ray was negative, my CT scan showed a pneumonia. Yes! I told you I was sick! So, pneumonia was my “source” of infection. That, coupled with my SIRS criteria, meant I had sepsis.

Two liters of iv fluids and some iv antibiotics later, I was on my way home. Did I feel better? Only ever so slightly that I was willing to rescind my DNR status (I’m joking). Actually, my fever and chills came back as I returned home, and I felt like death again. But, at least this time I had a diagnosis, and not a sissy diagnosis, either. Full-fledged pneumonia. Can you tell I revel in being validated as a “legit” patient? I woke up today markedly better.

There is a point to this story. Basically, when you feel so terrible, worse than you ever have, it’s probably time to be evaluated, even if you have the initials “MD” after your last name. Our bodies are remarkable at screaming at us when something is wrong. We just have to listen. What I had was early sepsis, something that is fairly easily treatable. But, without the fluid and the antibiotics, this would have progressed to severe sepsis or even septic shock. I’m convinced if I had not sought care from a colleague last night, I would have worsened to the point that I would be in the ICU today being treated for severe sepsis rather than sharing my good fortune with you.

What experiences have you had that left you with the thought you were glad you went to the hospital when you did?

Prevent getting hit by a Mack truck. Get vaccinated!

“Yeah, I had the flu yesterday. Much better now.”iStock_000000633147_Medium

“My kid had the stomach flu last week.”

“Man, my throat hurts. I think I’m getting the flu.”

Wrong. All wrong. The word “flu” gets thrown around a ton as a substitute for any of a number of respiratory or GI illnesses. They are not in the same game as The Flu. Not even the same sport. No. These other common ailments? They hear the word influenza and they shudder. Influenza is the T. Rex of the viral world.

I want you to take one thing away from this blog. Influenza: avoid it like the plague.

What’s the big deal? Well, first of all, influenza is very contagious. In fact, you can get it from someone even a day before he has symptoms. You’re infectious for a week after your symptoms start. On top of it, you feel horrible. Not like “my nose is running and my throat is scratchy.” No, more like being dragged behind an RV through the desert would be an improvement in my symptoms. Ok, I’ll admit, I just finished watching Breaking Bad.

So, fever, cough, congestion, body aches, chills, headache, fatigue. I’ve had patients tell me that even just moving their fingers were painful. Did I mention body aches? I consider that to be a hallmark bad symptom of influenza. And fatigue to the point you don’t even want to sit up in bed. Of all the people who come to the ED in their pajamas, these are the ones I might give a pass to.

These are just the walking wounded. Some people get really sick from the flu. Like, fatally sick. We’re not great at predicting who is going to get hit really hard.

This year, we’ve seen a lot of H1N1, the nasty influenza A strain that hit us so hard in the 2009-2010 flu season. Back then, H1N1 caught us off guard. By the time it was identified as traveling over from Asia, as the flu does, it was too late to get it in the vaccine. H1N1 was particularly vicious toward young, healthy people. If you were young, especially pregnant, and had a great immune system, H1N1 caused an exaggerated response of that immune system. There was more inflammation going on in the body, particularly the lungs. This year, as in previous years, we’ve seen fatalities from the flu, including some young, otherwise healthy people.

How do we diagnose it? Mostly I ask about your symptoms. We have rapid tests for influenza, but they aren’t sensitive enough to rule out the disease. If your story fits with influenza this time of year, you probably have influenza. It’s not rocket science.

Now, to let you into the mind of how the emergency physician thinks, what do I look for in the patient I think has influenza? Well, I look to see what other illnesses they have. Immune suppression from diseases or drugs, diabetes, obesity, and extremes of ages (the babies and the octogenarians) are all risks for badness. Then, I look at vital signs. The people who have low oxygen level, rapid breathing, and look sicker than just “I feel horrible” make me worry.

Now, there is antiviral medicine that may be helpful if started in the first 48 hours of the illness, but the data on its effectiveness is not great. If it does help, it probably shortens how long you’re sick by about a day. You’re sick 4-6 days without the medicine. You pay dearly for that 1 day improvement.

Want one more kick in the pants? There is some data that taking fever-reducing drugs like Tylenol and Advil may prolong the duration of your symptoms. If I get influenza, I’m taking some ibuprofen to help with my fever and my aches and pains. I’d rather hurt less for a longer period of time than roll over and let influenza do as it pleases. But, I’m a fighter. You do what you want.

Here’s an idea. How about an ounce of prevention? Yeah, even this far into influenza season it’s not too late to get vaccinated. It’s especially not too late to plan to get your shot this fall. Really, why go through this misery? Yes, sometimes you still get the flu because the vaccine isn’t perfect. But, you don’t get the flu from the vaccine. It just so happens you get vaccinated the time of year all the little wimpy respiratory viruses are going around. The influenza vaccine won’t help you with those. Man up, cupcake. Those are just a symptom of living.

Get vaccinated. You’re much better off using those sick days on a nice spring day when you would rather be kayaking. Shhh… I won’t tell. I’ll probably write you a work note.