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Audio: Interview With ACP President, Dr. Joseph Stubbs, About H1N1 Flu

stubbsThis year’s influenza season is unique in that there are additional strains circulating, with unclear medical implications for the US population. I interviewed Dr. Joseph Stubbs, president of the American College of Physicians, to get the inside scoop on what to expect this year with the H1N1 and seasonal flu strains. You may listen to the podcast or read a shortened version of the interview below.

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Dr. Val: Why are younger people and pregnant women more susceptible to H1N1 flu?

Dr. Stubbs: What we think is going on with younger people is that some of the genetic material of the H1N1 flu virus was part of the seasonal flu before the 1960’s. Older individuals may have an enhanced immune response to the novel H1N1 virus because their bodies can recognize it and fight it more effectively. Since younger people have never been exposed to this virus before, they’re more susceptible to it.

As far as pregnant women go, we’re not exactly sure why they’re at higher risk for complications from the H1N1 flu, but it’s possible that their susceptibility is related to changes in the immune system associated with carrying a baby. The immune system has to tolerate and accept the growing fetus – which happens to make it less effective at fighting off viruses.

Dr. Val: What’s the latest on the timing of vaccine availability? Do you think we’ll get it in time to head off an epidemic?

Dr. Stubbs: HHS Secretary Sebelius recently announced that the FDA has approved the novel H1N1 flu vaccine, and it appears that it will be effective with one shot. They’re hoping to make it available within the first 2 weeks of October, which is ahead of schedule. However, we still don’t know how much of the vaccine will be available, and how hard we’ll have to ration it. We hope that this will ward off a major pandemic. But here in Georgia, we’ve already been seeing a large number of cases.

Dr. Val: Should physicians prioritize their patients and give the vaccine to the at-risk groups first?

Dr. Stubbs: Right now we are planning to ration the vaccine initially to those who are at risk, which includes: healthcare providers, pregnant women, people who provide care for infants who are less than 6 months old, children 6 months to 24 years of age, and those ages 25-64 who have chronic illnesses that might cause them to have a more severe case of the flu. If we have enough supply then we’ll also vaccinate healthy adults and seniors. But seniors should make sure they get the seasonal flu vaccine this year.

Dr. Val: How does the H1N1 flu differ from the usual seasonal flu?

Dr. Stubbs: The seasonal flu vaccine continues to kill 30,000 of our citizens every year. The people who most need the seasonal flu vaccine are individuals over age 65, immunocompromised, and young infants. We expect the seasonal flu vaccine to be widely available and we recommend that almost everyone get that as soon as possible.

Dr. Val: Is the novel H1N1 flu virus related to the deadly Spanish flu of 1918 in any way?

Dr. Stubbs: They do share some genetic features, but not all.

Dr. Val: Are you concerned about the H1N1 flu virus mutating?

Dr. Stubbs: We certainly are, though we’re concerned about that with any virus. We’re most concerned about the flu becoming resistant to the anti-viral medicines that we have now like Tamiflu – which we use for people with serious cases of the flu.

Dr. Val: How do people know if they have a “serious” case of the flu?

Dr. Stubbs: If someone is experiencing severe shortness of breath within the first 48 hours of getting the flu, or if they have a severe headache and are not acting themselves or if they have uncontrollable diarrhea or vomiting, that requires medical attention.

Dr. Val: What’s the most important thing for Americans to know about the H1N1 flu?

Dr. Stubbs: The most important thing is not to panic. People should not crowd the ERs just because they think they might have the H1N1 flu – they should only go if their illness is severe as I described before. They should wash their hands frequently, and if anyone gets sick, stay home so you don’t spread it to others. The vast majority of people will get better within a few days.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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