Wednesday, October 28, 2009

Hospitals flooded with children with swine flu

From USA Today:

BALTIMORE — To Mitchell Goldstein, the flood of sick children seemed endless. Day after day, nearly three times as many kids as usual streamed into the rainbow-colored pediatric emergency room at Johns Hopkins Hospital, sniffling and feverish, worried parents hovering.

The press of children with swine flu was so relentless that doctors opened an annex in a hospital dining room to handle the overflow. "Our worst day" was Sunday, Oct. 11, says Goldstein, one of the ER doctors. "We had 15 to 20 patients an hour. It was 24/7. There wasn't a lull."

Last week, the epidemic of ailing children let up somewhat. But doctors here are expecting a new run of flu patients — the children's parents. "What we see first in (children) we see two to three weeks later in adults," says Trish Perl, the hospital's director of infection control.

The scenes at Johns Hopkins are being repeated at hospitals in Denver and Duluth, Seattle and San Diego, as waves of flu patients arrive at their doors, doubling their emergency room volume. Just as significant is the effect on intensive care units: A relatively small number of flu patients are requiring intensive care, but some are so ill they will need round-the-clock care for weeks.

Doctors at Johns Hopkins and elsewhere expect the number of patients needing hospitalization and intensive care to rise. Such an influx of intensive care patients eventually could force some hospitals to cancel services such as elective surgery, they say.

"Why did President Obama declare a national emergency? Because what's going on at Hopkins is happening across the country," Perl says. "An infection that generally doesn't appear to be severe is pushing hospitals to their limit."

The White House declaration, announced Oct. 24, was designed to give hospitals the flexibility to move patients to satellite facilities if they are overwhelmed in dealing with an outbreak that is now widespread in 46 states and afflicting millions of people, says Reid Cherlin, an administration spokesman.

"H1N1 is moving rapidly, as expected," Cherlin says. "By the time regions or health care systems recognize they are becoming overburdened, they need to implement disaster plans quickly."

Thomas Frieden, director of the Centers for Disease Control and Prevention, reported Friday that the swine flu virus, also known as H1N1, has killed more than 1,000 people nationwide and prompted 20,000 to be hospitalized. For the second week in a row, deaths from flu and pneumonia increased last week, reaching a total of 2,416 from Aug. 30 to Oct. 17. Ninety-five children have died of swine flu since April, 11 more last week, he says.

Seasonal flu typically kills about 36,000 people and hospitalizes 200,000, the CDC says.

Flu's unpredictability makes planning a challenge.

One scenario by the President's Council of Advisors on Science and Technology forecasts that if 30% of the U.S. population contracts H1N1 flu, 90 million could get sick, 1.8 million would be hospitalized and 30,000 or more would die. The Trust for America's Health, a non-profit public-health advocacy group, reported in early October that if the infection rate hits 35%, many states may run out of hospital beds, forcing hospitals to begin canceling elective procedures.

So far, hospitals have been taxed — but not to that degree.

"We aren't seeing the surge in hospitalizations that might be predicted with a huge attack rate," says the trust's executive director, Jeffrey Levi. "We're seeing a small segment of people who are hospitalized, incredibly sick and in need of treatment."

To many analysts, swine flu appears to be two overlapping epidemics: one a cascade of mild to moderate cases that is stressing hospital emergency rooms, and the second a narrow stream of unusually young patients who need intensive care.

At most hospitals, swine flu has had "very little impact on patient care — except in ICUs," says Eric Toner of the University of Pittsburgh Center for Biosecurity.

'We've been inundated'

Even so, many hospitals are struggling to keep up with the growing number of swine flu patients. Since May 1, doctors at Hopkins have treated 581 patients, 298 of them children, records show. Eighty-six adults and 96 children were admitted to the hospital. Thirty-four patients needed intensive care, 14 of them children. Three flu patients have died.

Connie Price, chief of infectious diseases at Denver Health, the city's public hospital, says, "I've been living this" since Aug. 28, when the hospital's lab reported 12 positive tests for swine flu.

"Since then we've been inundated," she says. "In a typical flu season, we may hospitalize 15 patients. With H1N1, we've hospitalized 10 times that many. We're not even in flu season yet."

In Rio Grande County, a rural community in the Rockies about 200 miles south of Denver near the New Mexico border, clinics were so overwhelmed with patients that they began turning away those who didn't have flu. With absentee rates of 40%, schools closed. Many of those children turned up in local clinics and emergency rooms.

"In San Luis Valley, we have three small rural hospitals. Flu burned through all of them in a couple of days," county health department spokeswoman Paula Hendricks says, noting that it was difficult to respond rapidly because the community is so remote it takes FedEx two days to deliver supplies from Denver.

P.J. Brennan, chief medical officer for the Penn Health System at the University of Pennsylvania in Philadelphia, says: "We're seeing in our health system right now about 40 to 50 patients a day with influenza-like illness. This is a significant increase over what we've seen (in the past), but not so much that we've had to implement our surge plan," annexing extra space and pulling in additional staff to handle overflow.

The surge of infections led thousands of people in communities across the USA to line up this week for vaccinations, which remain in short supply. As of Friday, 16 million doses of H1N1 vaccine were available for shipping, far fewer than the 40 million federal officials predicted would be available by now. Health officials have blamed the vaccine shortages on production delays among some of the five manufacturers churning out the swine flu vaccine.

The vaccine shortage is a major concern for doctors and nurses working with flu patients, especially for those who perform procedures that put them at high risk of infection. At Johns Hopkins, Perl, Sara Cosgrove and other members of the infectious-disease team routinely are accosted in the hallways by doctors not on the list who want vaccinations.

Topping the list of those being vaccinated first are pregnant health care workers or those working in areas of the hospital where they are most likely to be exposed to the virus. Next come pregnant patients, young patients with serious chronic diseases and patients ages 6 months to 4 years.

Last Wednesday, a doctor stopped Perl and Cosgrove in a hallway near the cafeteria, where vaccine was being offered to "high-risk" hospital staffers. "I'm in hematology. I work with immune-compromised patients," the doctor said. "One clinic a week."

A look from Cosgrove gave the doctor his answer: no. "This is the pressure I get from some of my own people," Perl said moments later.

Perl says vaccine supplies are too limited to vaccinate any but the most critical, front-line health workers. Although she declined to say how many doses of vaccine the hospital received, Perl says Johns Hopkins got just one-fifth of the amount it had ordered. One-quarter of the doses were given to high-risk patients, including children with asthma and cystic fibrosis. The remainder were divided up among front-line health personnel and Hopkins' three sister hospitals, which hadn't received any vaccine at all.

The next shipment isn't due until November.

Valerie Rhymer, a nurse who has worked at Hopkins for 47 years, got her H1N1 vaccination Wednesday. She says she gets her seasonal flu shot every year because she routinely performs bronchoscopies and other procedures on flu patients that can release flu virus into the air.

Vaccine is in such demand, says Deborah Dooley, clinical manager of occupational health, that the hospital pharmacy treats it like a controlled substance. "I'm one of two people who can take it out," says Dooley, presiding over the triage desk where health workers learn whether they're cleared for vaccination.

Many of these workers are on the list because they care for the sickest flu patients, a fraction of the total but a group in critical need of care. That's because, in some cases, H1N1 flu wreaks havoc within the lungs, causing blood clots and bleeding.

"It's impressive even to me, the damage done to these lungs," says Jeffrey Jentzen, director of autopsy and forensic services at the University of Michigan, who has performed postmortems on several H1N1 patients.

In some cases, patients hardest hit by the virus are children with asthma, cerebral palsy, cystic fibrosis and other neurodevelopmental disorders. Others are pregnant women, who account for a disproportionate number of deaths. In some cases, the flu has claimed otherwise healthy people with no apparent risk of severe disease. Perl calls some cases 1918-esque, referring to the dreaded Spanish flu that killed an estimated 675,000 people in the USA.

In one recent H1N1 case, Perl says, a previously healthy 30-year-old man landed in Hopkins' ICU and stayed there.

"It took us 2½ months to get him out of the hospital," she says.

Roy Brower, who is in charge of the ICU at Johns Hopkins, says that "there was a period of time when he was desperate, in terms of our ability to get oxygen in and carbon dioxide out. We were very worried about him."

Some patients' lungs are in such bad shape that doctors bypass them using an advanced ventilation technique called ECMO, for extra-corporeal membrane oxygenation, which works something like the heart-lung machines that are used during heart surgery.

The University of Michigan, which pioneered the technique, has started a national registry of H1N1 patients. As of Oct. 9, the latest data available, at least 54 flu patients have been so sick that they've needed a temporary lung bypass; 62.8% of those whose outcomes are known survived, says Pauline Park, co-director of the hospital's critical care unit.

Brower, of Hopkins, says doctors are still divided on whether the technique provides an extra benefit to patients with adult respiratory distress syndrome. But, he says, it represents one illustration of how far medicine has come since the 1918 epidemic, which occurred long before researchers discovered that flu was caused by a virus.

"They had no intravenous therapy, no antibiotics for patients who got super-infections with bugs like staph, no influenza vaccinations," he says. As a result, the death rate in the 1918 epidemic topped 2.5%. The death rate from H1N1 flu is, so far, a fraction of 1%.

Gabor Kelen, director of Hopkins' emergency department and its office of critical event preparedness and response, says the university system — with its liberal arts college and network of four hospitals — has been able to keep up with the epidemic's rapid growth through careful planning that began as soon as the first cases emerged in the spring.

"If we hadn't planned for this surge, it could have produced a deadly increase in volume that we couldn't have handled," he says. "The trouble is, we don't quite know how deep into this we are."