F/u Weird H1N1?

October 22, 2009

So, didn't need to wait, she called me. First dose of Tamiflu, he threw up, called pharmacy, not me, they said give again, she did. Then he refused to take evening dose d/t GI upset, but eventually did at 11 pm. Kept it down, woke at up 1am, with apparent hallucination or night terror, saying "my skin is on fire, I'm dying, can't you see, take me to the hospital", and screaming. Medics were called and came, by the time they got there, he was lucid, nl temperature, nl bs, pulse ox of 98%, and cleared to go back to sleep.

Absent in our discussion of whether to give the Tamiflu or not yesterday, we didn't get into the why not of SIDE EFFECTS, I discuss these possible side effects with the parents of the under 5 crowd, did not with this mother. She was very worried he was overdosed, compounded by the fact that the pharmacy was out of liquid suspension, so had to make it themselves from the 75 mg capsules, made a 75 mg/5 ml soln, rather than the 12 mg/1 ml, I Rx, but did give her accurate written rx to take equivalent to 60 mg bid. Which she thinks she did. Had to after the fact tell her, yes this is a known side effect, very uncommon, but does happen, you can stop the medicine or lower the dose. She not willing to stop the medicine, big believer it helped the rest of the clan, so lowered the dose to 45 mg bid and went over how many ml on the syringe etc. Now real benefit is totally moot I think at lower dose. However, he is only T100.5 this am, and feels better, no problems with increasing fatigue, or sob, etc, she is under strict instructions to call me daily with updates. They did not want to come in today d/t being up during the night.

Yes, I too have seen the kid who looks well, especially a teenage boy, but on CXR it's pneumonia. Do not believe it is this yet, and hope it won't become so. This mother is very cautious, I will know if there is even a hint of worsening.

I feel that this listserve has been a life saver, when I was starting the practice, and it's been so long since I have posted a clinical question, I forgot how nice it is to have someone to bounce things off of. It is isolating, so thank you to everyone who posted, whether you agree with me or had other points to bring up.

When I first started the practice I used to call my old group for curbsides, but haven't done that for a few years, I have something better now, a national panel of people who think and practice mostly like I do.

I agree that the best thing is having great same day access, know your families, because you have a small panel and you are the only one who sees them, and no better judge than the doctor in the room at that moment. I learned from a wise older FP long ago, not to second guess other doctors when a patient or someone else comes in with a story of what the doctor did do they shouldn't have, or didn't and should have. Generally patients don't remember the whole story, and/or don't tell the whole story, or didn't tell the original doctor the whole story, and you can only give each patient and doctor the benefit of the doubt, that they did the best they could in that situation. Wish I had a dime for every woman who told me she wasn't in an abusive relationship, and then later I found out she lied out of fear. But that's another issue.

So I will give more updates as they are available, obviously my office is slower today. I had 4 morning cancelations, I can go wks with none! I think they are all at home with fevers.

Cote' MD

Maple Valley, Wa

October 22, 2009

You are doing a great job with messy stuff .Must have gone to a good medical school...I too find this list serv far better than curbsiding colleguaes who are busy /who might not care/ and are half distracted.

Jean

So, didn't need to wait, she called me. First dose of Tamiflu, he threw up, called pharmacy, not me, they said give again, she did. Then he refused to take evening dose d/t GI upset, but eventually did at 11 pm. Kept it down, woke at up 1am, with apparent hallucination or night terror, saying " my skin is on fire, I'm dying, can't you see, take me to the hospital " , and screaming. Medics were called and came, by the time they got there, he was lucid, nl temperature, nl bs, pulse ox of 98%, and cleared to go back to sleep.

Absent in our discussion of whether to give the Tamiflu or not yesterday, we didn't get into the why not of SIDE EFFECTS, I discuss these possible side effects with the parents of the under 5 crowd, did not with this mother. She was very worried he was overdosed, compounded by the fact that the pharmacy was out of liquid suspension, so had to make it themselves from the 75 mg capsules, made a 75 mg/5 ml soln, rather than the 12 mg/1 ml, I Rx, but did give her accurate written rx to take equivalent to 60 mg bid. Which she thinks she did. Had to after the fact tell her, yes this is a known side effect, very uncommon, but does happen, you can stop the medicine or lower the dose. She not willing to stop the medicine, big believer it helped the rest of the clan, so lowered the dose to 45 mg bid and went over how many ml on the syringe etc. Now real benefit is totally moot I think at lower dose. However, he is only T100.5 this am, and feels better, no problems with increasing fatigue, or sob, etc, she is under strict instructions to call me daily with updates. They did not want to come in today d/t being up during the night.

Yes, I too have seen the kid who looks well, especially a teenage boy, but on CXR it's pneumonia. Do not believe it is this yet, and hope it won't become so. This mother is very cautious, I will know if there is even a hint of worsening.

I feel that this listserve has been a life saver, when I was starting the practice, and it's been so long since I have posted a clinical question, I forgot how nice it is to have someone to bounce things off of. It is isolating, so thank you to everyone who posted, whether you agree with me or had other points to bring up.

When I first started the practice I used to call my old group for curbsides, but haven't done that for a few years, I have something better now, a national panel of people who think and practice mostly like I do.

I agree that the best thing is having great same day access, know your families, because you have a small panel and you are the only one who sees them, and no better judge than the doctor in the room at that moment. I learned from a wise older FP long ago, not to second guess other doctors when a patient or someone else comes in with a story of what the doctor did do they shouldn't have, or didn't and should have. Generally patients don't remember the whole story, and/or don't tell the whole story, or didn't tell the original doctor the whole story, and you can only give each patient and doctor the benefit of the doubt, that they did the best they could in that situation. Wish I had a dime for every woman who told me she wasn't in an abusive relationship, and then later I found out she lied out of fear. But that's another issue.

So I will give more updates as they are available, obviously my office is slower today. I had 4 morning cancelations, I can go wks with none! I think they are all at home with fevers.

Cote' MD

Maple Valley, Wa

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

October 22, 2009

Thanks I completely agree about the curbsides.

Re: F/u Weird H1N1?

You are doing a great job with messy stuff .Must have gone to a good medical school...I too find this list serv far better than curbsiding colleguaes who are busy /who might not care/ and are half distracted.Jean

So, didn't need to wait, she called me. First dose of Tamiflu, he threw up, called pharmacy, not me, they said give again, she did. Then he refused to take evening dose d/t GI upset, but eventually did at 11 pm. Kept it down, woke at up 1am, with apparent hallucination or night terror, saying "my skin is on fire, I'm dying, can't you see, take me to the hospital", and screaming. Medics were called and came, by the time they got there, he was lucid, nl temperature, nl bs, pulse ox of 98%, and cleared to go back to sleep.

Absent in our discussion of whether to give the Tamiflu or not yesterday, we didn't get into the why not of SIDE EFFECTS, I discuss these possible side effects with the parents of the under 5 crowd, did not with this mother. She was very worried he was overdosed, compounded by the fact that the pharmacy was out of liquid suspension, so had to make it themselves from the 75 mg capsules, made a 75 mg/5 ml soln, rather than the 12 mg/1 ml, I Rx, but did give her accurate written rx to take equivalent to 60 mg bid. Which she thinks she did. Had to after the fact tell her, yes this is a known side effect, very uncommon, but does happen, you can stop the medicine or lower the dose. She not willing to stop the medicine, big believer it helped the rest of the clan, so lowered the dose to 45 mg bid and went over how many ml on the syringe etc. Now real benefit is totally moot I think at lower dose. However, he is only T100.5 this am, and feels better, no problems with increasing fatigue, or sob, etc, she is under strict instructions to call me daily with updates. They did not want to come in today d/t being up during the night.

Yes, I too have seen the kid who looks well, especially a teenage boy, but on CXR it's pneumonia. Do not believe it is this yet, and hope it won't become so. This mother is very cautious, I will know if there is even a hint of worsening.

I feel that this listserve has been a life saver, when I was starting the practice, and it's been so long since I have posted a clinical question, I forgot how nice it is to have someone to bounce things off of. It is isolating, so thank you to everyone who posted, whether you agree with me or had other points to bring up.

When I first started the practice I used to call my old group for curbsides, but haven't done that for a few years, I have something better now, a national panel of people who think and practice mostly like I do.

I agree that the best thing is having great same day access, know your families, because you have a small panel and you are the only one who sees them, and no better judge than the doctor in the room at that moment. I learned from a wise older FP long ago, not to second guess other doctors when a patient or someone else comes in with a story of what the doctor did do they shouldn't have, or didn't and should have. Generally patients don't remember the whole story, and/or don't tell the whole story, or didn't tell the original doctor the whole story, and you can only give each patient and doctor the benefit of the doubt, that they did the best they could in that situation. Wish I had a dime for every woman who told me she wasn't in an abusive relationship, and then later I found out she lied out of fear. But that's another issue.

So I will give more updates as they are available, obviously my office is slower today. I had 4 morning cancelations, I can go wks with none! I think they are all at home with fevers.

Cote' MD

Maple Valley, Wa

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/ MD ph fax impcenter.org

October 22, 2009

I wonder how one would cope if one had a major epidemic and you trying to manage as many people at home as best you could because hospital services were overwhelmed.There are scoring systems you can use to triage which ones need to be admitted, but they look time consuming to use.

Maybe if you had a web portal, you could get the care givers who were well enough to enter 4 hourly obs ..temp, resp, and maybe O2 if there were enough oximeters to go around. Then you could pick out those ones that needed more urgent attention.

Is there any such plans in the event of a major epidemic?

Thanks I completely agree about the curbsides.

Re: F/u Weird H1N1?

You are doing a great job with messy stuff .Must have gone to a good medical school...I too find this list serv far better than curbsiding colleguaes who are busy /who might not care/ and are half distracted.

Jean

So, didn't need to wait, she called me. First dose of Tamiflu, he threw up, called pharmacy, not me, they said give again, she did. Then he refused to take evening dose d/t GI upset, but eventually did at 11 pm. Kept it down, woke at up 1am, with apparent hallucination or night terror, saying " my skin is on fire, I'm dying, can't you see, take me to the hospital " , and screaming. Medics were called and came, by the time they got there, he was lucid, nl temperature, nl bs, pulse ox of 98%, and cleared to go back to sleep.

Absent in our discussion of whether to give the Tamiflu or not yesterday, we didn't get into the why not of SIDE EFFECTS, I discuss these possible side effects with the parents of the under 5 crowd, did not with this mother. She was very worried he was overdosed, compounded by the fact that the pharmacy was out of liquid suspension, so had to make it themselves from the 75 mg capsules, made a 75 mg/5 ml soln, rather than the 12 mg/1 ml, I Rx, but did give her accurate written rx to take equivalent to 60 mg bid. Which she thinks she did. Had to after the fact tell her, yes this is a known side effect, very uncommon, but does happen, you can stop the medicine or lower the dose. She not willing to stop the medicine, big believer it helped the rest of the clan, so lowered the dose to 45 mg bid and went over how many ml on the syringe etc. Now real benefit is totally moot I think at lower dose. However, he is only T100.5 this am, and feels better, no problems with increasing fatigue, or sob, etc, she is under strict instructions to call me daily with updates. They did not want to come in today d/t being up during the night.

Yes, I too have seen the kid who looks well, especially a teenage boy, but on CXR it's pneumonia. Do not believe it is this yet, and hope it won't become so. This mother is very cautious, I will know if there is even a hint of worsening.

I feel that this listserve has been a life saver, when I was starting the practice, and it's been so long since I have posted a clinical question, I forgot how nice it is to have someone to bounce things off of. It is isolating, so thank you to everyone who posted, whether you agree with me or had other points to bring up.

When I first started the practice I used to call my old group for curbsides, but haven't done that for a few years, I have something better now, a national panel of people who think and practice mostly like I do.

I agree that the best thing is having great same day access, know your families, because you have a small panel and you are the only one who sees them, and no better judge than the doctor in the room at that moment. I learned from a wise older FP long ago, not to second guess other doctors when a patient or someone else comes in with a story of what the doctor did do they shouldn't have, or didn't and should have. Generally patients don't remember the whole story, and/or don't tell the whole story, or didn't tell the original doctor the whole story, and you can only give each patient and doctor the benefit of the doubt, that they did the best they could in that situation. Wish I had a dime for every woman who told me she wasn't in an abusive relationship, and then later I found out she lied out of fear. But that's another issue.

So I will give more updates as they are available, obviously my office is slower today. I had 4 morning cancelations, I can go wks with none! I think they are all at home with fevers.

Cote' MD

Maple Valley, Wa

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/

MD ph fax impcenter.org

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

October 22, 2009

I have been wondering too- how if this were really something evil what a poor practice run this was - what relly would be doneif this were soemthign very awful?SOme sates have vaccines some do not. IN my state one county has gotten 100 doses and another has gotten 18,000 ! doses-data from state today. I sure have none from teh officcial sources

Some docs have regular flu vaccine some do not The Rite AIds do. The schools here just ran out No one really knowsmuch The vaccine s come in multiples of 100 doses only some nasal someIM. some single doses some not, no nasal for this group no shots for this, repeat teh shot in 21 maybe 28 days for this age, but seasonal flu a differnt age and wait 4 weeks

Docs are figurin g all this out fieldding questions and sick people on the fly YOu can get this vaccien for up to age 17 and that for under 4 etcetc IT is mind boggling MY neighbor and a nurse at another practice calledme yesterday to organize a bit and said she will not speak without the speciics in fron t of her, she is getting so confused

It is hectic and while my state is spewing out endless pieces of paper a tme they are overwheliming and not concise Folow this link for a roster bill that for a letter toparents this for the VIS. Which ison CDC anyway...

I got more info from Shaorn McCOy in a few brief emails on what to do withteh differnt types of vaccines and from just going to CDC than all this other stuff The state wheer i live wants docs to agree to be distribution centers Meaning find your own shots folks, order them up in quanitties of 100 and hope you figured out howmany of each group you need and can share or can get dfrom someone else and have people coming to your office to get them or run allover to getones you need

and weekly reporting record keeping by group by type of vaccien is required Meanwhile our phones are ringing off the hook with questions.If you ask me calm concise organizing with effective dsitribtuion- didnot happen .

I do like lining up the families and squirting all their noses though

I wonder how one would cope if one had a major epidemic and you trying to manage as many people at home as best you could because hospital services were overwhelmed.There are scoring systems you can use to triage which ones need to be admitted, but they look time consuming to use.

Maybe if you had a web portal, you could get the care givers who were well enough to enter 4 hourly obs ..temp, resp, and maybe O2 if there were enough oximeters to go around. Then you could pick out those ones that needed more urgent attention.

Is there any such plans in the event of a major epidemic?

Thanks I completely agree about the curbsides.

Re: F/u Weird H1N1?

You are doing a great job with messy stuff .Must have gone to a good medical school...I too find this list serv far better than curbsiding colleguaes who are busy /who might not care/ and are half distracted.

Jean

So, didn't need to wait, she called me. First dose of Tamiflu, he threw up, called pharmacy, not me, they said give again, she did. Then he refused to take evening dose d/t GI upset, but eventually did at 11 pm. Kept it down, woke at up 1am, with apparent hallucination or night terror, saying " my skin is on fire, I'm dying, can't you see, take me to the hospital " , and screaming. Medics were called and came, by the time they got there, he was lucid, nl temperature, nl bs, pulse ox of 98%, and cleared to go back to sleep.

Absent in our discussion of whether to give the Tamiflu or not yesterday, we didn't get into the why not of SIDE EFFECTS, I discuss these possible side effects with the parents of the under 5 crowd, did not with this mother. She was very worried he was overdosed, compounded by the fact that the pharmacy was out of liquid suspension, so had to make it themselves from the 75 mg capsules, made a 75 mg/5 ml soln, rather than the 12 mg/1 ml, I Rx, but did give her accurate written rx to take equivalent to 60 mg bid. Which she thinks she did. Had to after the fact tell her, yes this is a known side effect, very uncommon, but does happen, you can stop the medicine or lower the dose. She not willing to stop the medicine, big believer it helped the rest of the clan, so lowered the dose to 45 mg bid and went over how many ml on the syringe etc. Now real benefit is totally moot I think at lower dose. However, he is only T100.5 this am, and feels better, no problems with increasing fatigue, or sob, etc, she is under strict instructions to call me daily with updates. They did not want to come in today d/t being up during the night.

Yes, I too have seen the kid who looks well, especially a teenage boy, but on CXR it's pneumonia. Do not believe it is this yet, and hope it won't become so. This mother is very cautious, I will know if there is even a hint of worsening.

I feel that this listserve has been a life saver, when I was starting the practice, and it's been so long since I have posted a clinical question, I forgot how nice it is to have someone to bounce things off of. It is isolating, so thank you to everyone who posted, whether you agree with me or had other points to bring up.

When I first started the practice I used to call my old group for curbsides, but haven't done that for a few years, I have something better now, a national panel of people who think and practice mostly like I do.

I agree that the best thing is having great same day access, know your families, because you have a small panel and you are the only one who sees them, and no better judge than the doctor in the room at that moment. I learned from a wise older FP long ago, not to second guess other doctors when a patient or someone else comes in with a story of what the doctor did do they shouldn't have, or didn't and should have. Generally patients don't remember the whole story, and/or don't tell the whole story, or didn't tell the original doctor the whole story, and you can only give each patient and doctor the benefit of the doubt, that they did the best they could in that situation. Wish I had a dime for every woman who told me she wasn't in an abusive relationship, and then later I found out she lied out of fear. But that's another issue.

So I will give more updates as they are available, obviously my office is slower today. I had 4 morning cancelations, I can go wks with none! I think they are all at home with fevers.

Cote' MD

Maple Valley, Wa

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/

MD ph fax impcenter.org

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

October 23, 2009

I completely agree, this hasn't been handled very well. Last night on the news here, pregnant reporter, showing how hard it was to find dose for her or anyone. King Countly Health dept has, but only if you have no insurance, no medical coupons, etc,and even still don't think they have enough for everyone. Swedish hospital, large for profit mecca got 18,000 doses, but all for their"health care workers" excuse me, how many? Harborview, mecca for the poor and training site extra-ordinary got 200 doses, excuse me?, I got 200 doses myself. This is ludicrous, here they just had everyone ask for what they wanted, some wanted none or didn't ask for enough, others, Swedish, too much unless it is going to patients. The health dept is saying they won't publish the sites where they shipped vaccine, because they don't want the public to overwhelm the system. Thank god this isn't actually a very deadly strain.

Cote' Re: F/u Weird H1N1?