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(Announcer)
Major funding for "Second Opinion" is provided by the Blue Cross and Blue Shield Association. An association of independent blue plans. Committed to better knowledge leading to better, more affordable healthcare for consumers.
(clock ticking)
(music)
(Dr. Peter Salgo)
Welcome to "Second Opinion", where each week we solve a real medical mystery. When we close this file a half an hour from now, you will not only know the outcome of this case, you will be better able to take charge of your own healthcare. I'm your host, Dr. Peter Salgo. And our story today concerns Emily. Now you have already met our special guests who are joining our cast regulars, primary care physician, Dr. Lisa Harris, and health reporter Christine Rogers. Now no one on this team knows this case. So let's get right down to work. Sixty-seven years old is how old Emily is. And she is a snowbird. She and her husband spend the winters down south in the United States. But this winter for a brief period however, they went on vacation. They went to China. Now it's the end of February. She just got back from China two days ago. And she's not feeling all that well. And she is complaining of 104 fever. Her breathing is quite rapid. And her husband says she is confused. Lisa, you're in the emergency room. What do you want to know? What are you going to do?
(Dr. Lisa Harris)
I'm a little worried about her being in China and coming back with a temperature that high with sudden onset. I mean there is a few things that kind of pop into your mind. The very first thing you want to do always is get a full set of vitals.
(Peter)
Okay.
(Lisa)
Try to get a better history. And a physical exam. So I need to know what her lungs sound like. I need to know what her heart sounds like.
(Peter)
Want to put her on oxygen in the meantime. Start an IV.
(Lisa)
I need to get a pulse ox first before I put her on O2 and then - always put in a line.
(Peter)
80 percent, I got some numbers for you.
(Lisa)
Okay.
(Peter)
80 percent saturated on -
(Lisa)
And that's correlating with her heart rate.
(Peter)
It is. Her respiratory rate is 34. Her heart rate is 140.
(Dr. Lisa Harris)
In other words we're going to put on some oxygen.
(Dr. Peter Salgo)
Okay.
(Lisa)
And I am sorry, what was her heart rate?
(Peter)
Heart rate is 140.
(Lisa)
Yeah now I am really getting a little concerned here.
(Peter)
Okay.
(Lisa)
And so we're going to start an IV.
(Peter)
Okay.
(Lisa)
Running wide open.
(Peter)
Okay. She's got muddled skin. A bright red throat. There is no breath sounds in her left lower lobe. And she is certainly confused. What do you think is wrong?
(Lisa)
Chest X-rays?
(Peter)
Chest X-ray we don't have back just yet. But they sent one off.
(Dr. Lisa Harris)
Okay. So we're worried about pulmonary processes, some sort of infectious disease thing. So and you want to know about pneumonia. If it is low guard pneumonia, certainly influenza is on your list. SARS is on your list.
(Dr. Peter Salgo)
Now the doctor does ask her husband for some more information. And the husband says that they got back from China. On the day they got back she started complaining. Muscle aches, runny nose, cough, sore throat. She took some Tylenol. Her eyes hurt. And then the confusion was just that morning, the morning she came into the emergency room. Does that help you at all?
(Lisa)
Doesn't help differentiate anything from - that's already on the list.
(Peter)
Any tests you would want to send off?
(Lisa)
I want a set of blood cultures. I want a CBC and DIF for starters. I want an influenza swab just for starters.
(Peter)
Okay. Okay. Do you want any sputum?
(Lisa)
Surely, if we can get it.
(Peter)
Her sputum was positive for grand positive clusters. Her rapid flu screening was positive.
(Lisa)
For?
(Peter)
That's all I have here. It's positive. So what's going on with Emily? What do you think?
(Lisa)
Well Emily appears to have influenza. And she has an infiltrate in her lungs. So in other words, it looks like the influenza has effected her respiratory tree. And she is acutely critically ill. And sounds like she may need to go into the intensive care unit for additional therapy.
(Peter)
Blood pressure is 80.
(Dr. Lisa Harris)
Yes.
(Dr. Peter Salgo)
We hear the word flu thrown around all the time. And she had a positive flu test. What is the flu?
(Dr. Kathleen Gensheimer)
Flu really stands for influenza. Which is exactly the sort of syndrome you describe rapid onset of body aches, loss of appetite, fever. Usually a little bit lower than what you described in your patient, 101, 102. Cough, runny nose. But the hallmark characteristic of influenza is truly feeling like you have been hit by the Mac truck. And you are just absolutely off your feet. Just almost wanting to die because you feel so awful. So what I would like to know about this 65-year-old lady is did she have her influenza vaccine? Because this is one of the most incredible preventative tools that are out there, and so much ignored by the populous because somehow they think if they get their flu shot it's going to give them "the flu".
(Peter)
That information is not in the chart at this point. It may be there later. But so far, we don't know that. We hear a lot of talk about kinds of flu, which is the flu you get the seasonal flu every February, which I suspect what you're talking about. And then there is the stuff you hear about in the news, the pandemic flu. What's the distinction?
(Kathleen)
Well seasonal influenza is exactly what you are describing, something that goes around in the winter months in the United States. What we never exactly know is, when it will arrive, how long it will stay. This is to distinguish from a pandemic strain, which is a totally new novel virus to which basically the entire populous is totally vulnerable and susceptible.
(Peter)
What about those gram positive cocci in clusters? Anybody worried about them?
(Dr. Edward Walsh)
Well sure. I mean one of the complications of influenza is bacterial super infection.
(Peter)
What does that mean?
(Ed)
Well, influenza is well known to do a lot of damage to your respiratory tree leading you then to susceptibility to common bacteria that carry in your nose, your throat. And it can go on to lead to a super infection. It could actually occur right away or it can occur sometimes after the influenza is actually resolved.
(Peter)
Before we go any further, how do you catch the flu? How do you get it?
(Ed)
Oh in many different ways. You can sit on a bus next to somebody who has got influenza and catch it. You can more commonly catch it from your children, because they are in fact probably the greatest spreaders of influenza.
(Lisa)
Secretions.
(Peter)
Do you have to breathe it in? Or can you touch things - what's the deal?
(Lisa)
If it's in your -
(Dr. Peter Salgo)
Or your grandchildren.
[chuckles]
(Lisa)
So if it is in your sputum, if it's in your nasal secretions. You know if you cough into your hand and then you start shaking hands with people. So universal precautions is one of the you know washing your hands, and using Kleenex and things like that are important.
(Ed)
Well I think people spend a lot of time talking about the aerosol transmission. That is the ability to spread it without actually coming in contact with an individual. And accounting for a lot of its transmissibility so that we breathe it in.
(Peter)
I want to get back to Emily. Because I am worried about her. I mean here we have a positive flu test. And what bugs me - no pun intended, are these gram positive cocci. She has staph cocci in her sputum. And a temp of 104. What you have already said is, probably a little high for just flu. What do you think is wrong?
(Lisa)
Well as we already said, she has a super infection.
(Peter)
Is it fair to say she has staph pneumonia? Staphylococci causing a pneumonia?
(Ed)
Well we don't know that. Yet. I think that the diagnosis of the bacterial pneumonia can be difficult. I think the suspicion here is certainly high enough to warrant antibiotic therapy. The chest X-ray may be of some help here. Influenza pneumonia may look somewhat different than say staphylococci pneumonia.
(Peter)
The X-ray shows an infiltrate, a socked in area of her lung exactly where the breath sounds were down. And I also have access to her blood cultures, which came back fairly quickly. And she is growing staphorious in her blood. So up to the ICU they go, where she is monitored. She is put on a ventilator. This is a sick woman. How sick on a scale of one to 10 do you think she is? Where would you put her?
(Dr. Lisa Harris)
I'd put her at a nine.
(Peter)
A nine. She is likely to die. Is that right?
(Dr. Edward Walsh)
I wouldn't say she is likely to die. I would say she may die.
(Kathleen)
I would also - you know I don't know what her underlying health status is too. She is an otherwise healthy 65-year-old lady. She may do better than if she has got all sorts of chronic problems that have served as issues in the past such as diabetes or asthma.
(Peter)
Can people die from the flu even if they don't have super infection, a bacterial infection plus the influenza?
(Ed)
Oh absolutely.
(Lisa)
Absolutely
(Kathleen)
Every year in the United States 36,000 Americans die of influenza. It's one of the leading causes of infectious disease mortality in this country.
(Dr. Peter Salgo)
Now Jim, you have had some family experience with this. Tell us a little bit about that.
(Jim Dooher)
My maternal grandparents died in the Spanish flu of the second decade of the 20th century - that was to say it was World War I. So I never knew my grandparents. They weren't you know poor people. They weren't just off the boat. They were a fairly substantial family.
(Peter)
You've done some work on this. You know a lot about the Spanish Flu Pandemic. Tell us a little bit about it.
(Donald McNeil Jr.)
I wish I knew more about it. It was a - it came in several waves. One theory is that it began in military camps in Kansas, went to France with the troops. Came back in a milder wave, and then came back in a much larger wave at the end of 1919. And hit particularly through Boston and Philadelphia and went West and ultimately I think - people dispute how many people died in the epidemic. But some estimates say as many as 100 million people may have died.
(Peter)
I mean this - I have heard and you guys confirm this for me if you can. This could have been the single greatest loss of life due to an epidemic since the Middle Ages, and since the Black Death. Is that a fair description?
(Donald)
It may have been greater.
(Kathleen)
Look at the population.
(Lisa)
Yes, look at the population. Yes.
(Donald)
Like this killed a third of Europe. So you can call it a third of the world. But -
(Peter)
Uh-huh. You had experience with flu in addition to your grandparents who were killed by the pandemic of 1919. What was your experience with the disease?
(Jim)
It is the worst infection that I have had in my adult life.
(Peter)
Tell me about it.
(Jim)
I was in an ICU section for four days plus. I was discharged after seven days on oxygen. And it was only after I had gotten away that I took a mental review of what I had been through. And really realized what a serious illness I had survived.
(Peter)
You also had some other medical problems prior to catching it.
(Jim)
Oh yes.
(Dr. Peter Salgo)
Is that right?
(Jim)
Yes. I am cardiac on several - I have had an MI, I have had a cardiac arrest subsequent to the MI.
(Peter)
MI means a heart attack.
(Jim)
Yes. A myocardial infarction.
(Peter)
Right.
(Jim Dooher)
A heart attack. But that's to distinguish it from the cardiac arrest, I had -
(Christine Rogers)
Did your primary care physician recommend you get a flu shot?
(Jim)
Oh he always does.
(Peter)
He was predisposed because of all sorts of conditions. We know that anybody can get the flu. But typically, what are those things in people who catch the flu that make them really worry?
(Kathleen)
Well the recommendations that are put forth nationally for those who should be immunized would certainly be anyone over the age of 65. People who live in institutions such as nursing homes. Those with underlying health problems such as cardiac conditions, heart conditions, lung conditions that you are describing that you may have. Pediatric patients now up until six months to five years of age is a brand new recommended age group because we recognize that there is a very elevated risk of hospitalization amongst very young children. And pregnant women because of the potential adverse consequences upon them. Anyone pediatric wise who is on long-term aspirin therapy. The list goes on and on and on. And I think at some point in this country, we will probably see universal recommendation for influenza vaccine. And I hope that we get there at some point.
(Peter)
Okay. Let's pause just for a minute, because I want to sum up a few of the things we have discussed already. Influenza comes in different types. There is seasonal influenza. There is pandemic influenza. But even seasonal influenza can cause serious health problems and death, especially for those with underlying health concerns. It is a nasty disease. Is that fair? Everybody agree to that?
(Lisa)
Very fair
(Peter)
Then let's move right along. Because I want to tell you a little bit more about Emily. She is up in the intensive care unit. She is on a ventilator. She is getting fluid and antibiotics. Her blood cultures as you know are growing staph, bad bug. She is on life support essentially. And her blood pressure is falling now rapidly enough, they put her on blood pressure support medications. What I can tell you is that she got a flu vaccine. Emily had a flu vaccine back in September. This is February now. So how come she got the flu? You love this vaccine.
(Dr. Kathleen Gensheimer)
I love the vaccine. And I love to try to dispel the myths around the vaccine. So number one myth we have already dispelled is that influenza shot will give you the flu. The other thing is, is that first of all, no biological product is 100 percent. So we know that there are some people who may still get sick despite the vaccine. But the vaccine is what we have. And certainly is well worthwhile, continuing to promote. We also know in the elderly or individuals with underlying health problems that their level of antibody response to the vaccine may not really go for a six-month time period. If this Emily got vaccinated in early September, and it is now late February, we're several months down the road from when she may have been vaccinated. So that's a possible explanation. But we also have to think about whether or not she may have been infected with an influenza virus strain that is not contained in this year's vaccine formulation.
(Ed)
In this particular case there are two concerns. One is the vaccine may just not have protected her completely from influenza. This does happen. It's not a perfect vaccine. You can still become infected. And certainly you can still get the bacterial super infection.
(Peter)
She got the vaccine in September. At least in part because she was afraid they would run out.
(Kathleen)
Getting your vaccine in September is actually recommended. Because what we want to do is not create perhaps a special healthcare visit. But when individuals start presenting to their physicians beginning in September, or as soon as the vaccine's available, they should take advantage of that healthcare opportunity and vaccinate.
(Dr. Peter Salgo)
Now she was in China. We have heard all the stories coming out of China. The Chinese government may be covering up the magnitude of the influenza epidemic. There is Avian flu. What is going on over there? Could she have acquired a flu virus in China? Do you think that we are unprepared to deal with it in this country?
(Donald)
You're asking a reporter?
(Peter)
I am. What do you see in China?
(Donald)
Look, people catch flu everywhere. Just because somebody comes back from China with the flu doesn't necessarily mean she has got Avian flu.
(Kathleen)
This is what we are watching very, very carefully as the scenario in Southeast Asia evolves, because of this Avian influenza. Avian referring to chickens. And an influenza strain that is creating chaos amongst the poultry flocks in Southeast Asia. And now in other parts of the world it spreads into Africa and Eastern Europe.
(Christine Rogers)
I think it's important maybe we make the distinction. I mean what is Avian flu?
(Peter)
What is Avian flu?
(Donald)
Avian flu is really a sort of headline nickname for what we are talking about. I mean the truth is that all flus were originally Avian flus. All flus originally come from birds. But then they get into humans. They get into pigs. They get into other animals. But this flu that everybody is worried about is a flu called the H5N1 because of the hemogluten (INAUDIBLE) base spikes on its outside.
(Peter)
And he wonders why we are asking him. Keep going.
[chuckles]
(Donald McNeil Jr.)
And the H5N1 is basically a bird disease right now. Not a disease of anything else. However, there have been 200-odd cases in humans of which 100-odd cases have been fatal. And that's what makes it scary.
(Christine)
It isn't a concern though now. I mean we know it was going from the birds to people. But now the concern is can it be transmitted person-to-person.
(Peter)
Let's take a quick break if we can. And sort of sum up what we have done so far. Again, a lot of ground covered over here. Flu vaccines do work. But they are not 100 percent effective in preventing seasonal influenza. Nothing in medicine is 100 percent. They will not protect us against pandemic flu. It's another virus for which there is no vaccine. However, getting the flu shot can lesson the severity of the flu if you get it; keep you from infecting people who are at high risk from suffering deadly flu related complications from your flu. So, a good idea all around to get the flu vaccine. So I can give you a little bit more information about Emily. She does not have the Avian, the pandemic flu as far as we can tell. I could also tell you that her spinal fluid is negative for staph, and that her temperature is beginning to fall, although they are not giving her anything to make it fall other than antibiotics. And that her oxygenation is a little bit better, this is now about 24 hours, 36 hours into her hospital course. Now, I want to get back into this pandemic flu stuff. Emily is doing a little better so we can let her be in the hands of her doctors for a few moments. How likely is it that this pandemic is going to come, whether it is Avian flu or something else? Is there certainly going to be another pandemic flu at some point?
(Kathleen)
There will be another pandemic. It's just inevitable. But when that will occur, how bad it will be, what virus is ultimately - whether it is this H5N1 or some other virus, those are the answers to those questions we just don't have.
(Peter)
Let me play devils advocate for a minute. And let me just represent the average person in this country. What's the harm that this person will ask me, I am asking you for this person, having some Tamiflu flu at home?
(Kathleen)
People should not stock pile anti-virals. That's another question that's been a very, very -
(Dr. Peter Salgo)
Let me see if I heard you right. They should not.
(Kathleen)
Should not stock pile antivirals.
(Peter)
Stockpile - why not?
(Dr. Kathleen Gensheimer)
If you come down with a cough, fever, it may or may not be influenza. Chances are it's probably one of these other hundreds of respiratory viruses. And they will not respond to an antiviral. So if people are going to start hording antivirals, taking them for the wrong indications, we may actually number one not only have enough antivirals for people who really need it now during seasonal influenza outbreaks, but we could also potentially within this use of antivirals, end up with a potential resistant organism if they are inappropriately utilized.
(Donald)
If every American stockpiled their own personal little piggy supply of Tamiflu, then the millions of people who would need it in other countries where the actual epidemic is more likely to break out, wouldn't have it.
(Peter)
Now Jim, you had Tamiflu, is that right?
(Jim)
Yes.
(Peter)
And when do you protect yourself? Do you get the flu shot now?
(Jim)
Well I will take a flu shot this fall.
(Peter)
What is this stuff anyway? And how does it work? How do you take it? Let's put this one to bed.
(Ed)
Well the simplest one is the Tamiflu. And that's an oral drug. You take it twice a day for five days for standard seasonal flu.
(Kathleen)
For treatment
(Ed)
For treatment. Or you can take it prophylactically. That is, if you potentially would be infected by it. And it has some relative benefit. In other words, it does not make you better tomorrow. It shortens the symptoms of flu by a day or so. It may also decrease the problems that we saw in this patient. For instance, bacterial super infections might be reduced somewhat.
(Christine)
I'm just wondering have we ever studies people who never get the shot? I'm one of them. I've never had the flu shot, I will admit. And I have never had the flu.
(Ed)
Well the majority of studies that have been published indicate that flu vaccine has between - and it depends on the age group you are talking about and the population, has between a 50 to 80 percent efficacy. Meaning that it's beneficial in 50 to 80 percent of the people. Now it varies. Unfortunately, the flu vaccine works best in the people who need it the least. That is young, healthy strapping 30-year-olds. It's least effective in your 80 and 90-year-olds. It's intermediate in your 60-year-olds. People who have diabetes or heart failure, or emphysema, or renal insufficiency for instance, they have a less effective vaccine effect.
(Jim)
But it says to me as a layman, that the advocacy of antivirals implies that you are willing to use a cannon to shoot a ant. But -
(Ed)
Well I wouldn't say that. I might turn it around and say that we have a pop gun to shoot an elephant. [chuckles]
(Peter)
Well let me back up. Maybe this vaccine business, as good as it is or as imprecise as it is, maybe it wouldn't be as necessary if people didn't get the flu in the first place. So are there some general public health measures that people can follow to keep themselves relatively flu-free?
(Dr. Edward Walsh)
Other than becoming a hermit during the winter, it would be very difficult to guarantee that you won't get the flu.
(Lisa)
Making sure that we get people immunized early on, early - you know before the season really begins is of paramount importance. And teaching the public to know what the warning signs are. What are the symptoms of influenza?
(Kathleen)
If we could get the public to demand the influenza vaccine, we would get the manufacturers to produce more vaccine, we would have those plants up and running. And if we did indeed have a pandemic, we might be in a better situation as far as perhaps having the - just the basic manufacturing base in order to be able to produce this vaccine once the seed virus isn't all ready to become available.
(Ed)
There is an additional problem. The vaccine that we currently use is made with technology that began in the 1940s. It hasn't changed very much. It's in chicken eggs. Whereas the need really now for a true pandemic from an Avian vaccine will probably outstrip that manufacturing capacity instantly. And we really need newer better and more effective means of producing vaccines. It's going to be very difficult to completely avoid influenza on a seasonal basis. And it's one of the reasons why for seasonal influenza, vaccines are so important.
(Kathleen)
But the other thing is that we are not even sure about the transmission actually. We could debate whether it is airborne, whether it is this large drop that comes through coughs or sneeze. Or what is the contribution of door handles and toilet seats or whatever. But you know I think probably the biggest concern would really be that coughing and sneezing person. And if we could just get society to start to really shame those people who go out during influenza season, working when they are obviously very, very sick. Get them to stay home. I actually think without making the well people stay home in their little isolated balloon, that we could actually do a lot to try to reduce transmission of normal seasonal influenza.
(Dr. Peter Salgo)
And with that, let's pause for a minute. Other than a vaccination, there are practical steps that you can take to prepare for seasonal flu and pandemic flu that can prevent you from becoming ill and lesson your symptoms or keep you from infecting others. And these would include washing your hands regularly. Using tissues. Avoiding crowded areas. Not touching doorknobs then not washing your hands and then touching your face. These are just bad ideas. Let me tell you a little bit more about Emily. Emily got a little bit better. After 48 hours she was off the blood pressure medicine. Her fever came down. Her oxygen content in her blood went up. She was off the ventilator. And she eventually went home. Six months after being discharged, she was still feeling awful. In fact, she had to go to rehab out of the ICU before going home. And she still doesn't feel very good. Now Jim, it's been six months since you had the flu. How are you doing?
(Jim)
I feel worse than Emily. [chuckles]
(Peter)
Is that right?
(Jim)
It leaves you without your normal - without even perhaps 30 percent of normal of your level of stamina. I can't walk 50 yards without becoming almost totally winded. The after effects are very heavy, very long lasting. I have no idea when they will finish. And how well I may feel afterwards.
(Peter)
Jim, thank you so much for sharing your story with us. I think we really ought to take a moment now and just sum up everything that we have discussed. Seasonal influenza can cause serious health problems and it can cause death, especially for those with underlying health concerns. Flu vaccines do work, but are not 100 percent effective at preventing seasonal influenza. And will not protect us against pandemic flu. But often, getting a flu shot might lesson the severity of the flu; keep you from infecting people who are at risk of suffering deadly flu related complications from the flu that you might give them. Other than a vaccination, there are practical steps that you can take to prepare for seasonal flu and pandemic flu that could prevent you from becoming ill, and lesson your symptoms, or keep you from infecting others. And these would include washing your hands regularly, using tissues, and avoiding crowds. And our final message is this. Taking charge of your health means being informed and having honest communication with your doctor. I'm Dr. Peter Salgo, and I will see you next time for another "Second Opinion".
(Announcer) Search for health information and learn more about doctor patient communication on the "Second Opinion" website. The address is pbs.org.
(music)
(Announcer)
Major funding for "Second Opinion" is provided by the Blue Cross and Blue Shield Association. An association of independent blue plans. Committed to better knowledge leading to better, more affordable healthcare for consumers.
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