Flu knows no boundaries. Such was the lesson learned by the physicians working in the remote Western Alaska city of Bethel. Nestled amid vast tundra, on the banks of the Kuskokwim river, Bethel is the hub city for the predominantly Yupik Eskimos that have called this region home for at least a thousand years. This year, the brief Alaskan summer came to an end with the rapid spread of Novel H1N1 influenza. Alaska as a whole did not see any H1N1 last spring with the first cases not hitting until August. Once cases began in the Bethel region, they rapidly increased until the ED census was 30% above last year for both the month of August and September. Already operating at capacity with 19,000 annual visits, the 11 bed ED was rapidly overwhelmed, requiring near disaster level response. As a remote IHS funded, tribal hospital staffed by 2 EPs, a dozen FPs and a handful of pediatricians, resource utilization was a major hurdle. Hospital-wide teamwork allowed for the management of the initial flood of patients, who were predominantly minimally affected or worried well. Strategies including: after hours clinic staffing, free dispensing of acetaminophen and ibuprofen in the hospital lobby, extended pharmacy hours, and administrative pay for ill employees helped keep the patient flow moving.
The second phase of the epidemic has now hit with a marked increase in pediatric patients presenting with pneumonia and exacerbations of their baseline asthma and chronic lung disease. Further, there has been a frightening increase in previously healthy individuals presenting with fulminent respiratory failure. Each week for the last month several of these patient have been intubated, stabilized, and packaged for the 400 mile flight to the nearest ICU in Anchorage. None of these patients have had significant medical history: from a 16-year-old basketball player who presented with sepsis, pneumonia and empyema to the 29-year-old father of 5 who presented with multilobar pneumonia and rapidly developed ARDS. These patients are the average Joes of our community, the breadwinners and the parents. As our community is shipped away one at a time we look towards an uncertain winter. With the suggestion of a bad seasonal flu and an expected bad RSV season more of the same is expected. Contingency plans are in the works to create a makeshift ICU should the Anchorage ICUs fill to capacity. Regardless, the daily rituals of the ED continue.
The census for September at my urban/community academic center in Nebraska was up. Our LWBS numbers were also up and as a result, our department has opted to lengthen our shifts to increase the hours of overlap when there are multiple attendings working. We will be paid for our extra time, but since the last hour of our shifts were previously meant more for tidying up and not seeing new patients, it is likely we will all be staying even later than usual now that we are also being asked to see patients right up until the end of our shifts. The time that we stay late is not paid, of course, and when you have three residents presenting 7 patients to you in the last half hour of your shift it is impossible that you will get out on time. However, this is the only solution that the powers that be have come up with to deal with increased census for now.
In downtown Baltimore, our census is up about 25%. This is also true of surrounding EDs. Peds volumes are more notably increased. Seasonal influenza vaccine has essentially run out and the H1N1 vaccine is arriving in batches. Unfortunately, the CDC recommendations for prevention of spread are often difficult to implement on the ground. The vast majority of people we are seeing have a relatively early seasonal influenza. We are all engaged in a number of activities to handle the influx and contagion: cohorting, masks, changes in visitor policies, vaccination clinics, figuring out appropriate testing and use of tamiflu, establishment of separate triage units, etc…
Given the H1N1 data that we have currently in hand, it is inappropriate to mandate vaccination for anyone. Mortality for H1N1 is low – no higher than seasonal flu and maybe lower – and the clinical studies have been meager (small numbers, no control groups, evidence of antibody response but no evidence of protection from illness). If the balance of risk shifts (fall outbreaks prove to be very deadly or affect millions and millions) I am open to prophylactic mandatory measures. Until then I believe it is bad science and bad policy.
