Swine flu comes home: a GP’s tale

So there we were, early Wednesday afternoon, preparations under way for the evening surgeries, when the phones started to ring off the hook. Almost simultaneously we got an email from the PCT telling us that 143 children from the local primary and infant schools were sick with an as yet unidentified viral illness. Some were being swabbed for swine flu and we were to have a low threshold to swab any child we saw, especially as small children with swine flu don’t always fit the diagnostic algorithm we’d been asked to use until now. And¬†yes, before you tell me, I know I’m meant to call it H1N1 but no one out in the community actually does.

Anyway, by now parents were beginning to phone in for advice and their anxiety levels were high. Our receptionists all had copies of the HPA advice but nothing had prepared them for either the volume of calls, or the near panic displayed by some of the parents of these very young children, and they were already starting to show the strain and needed help. We decided that a GP would call back all concerned parents and by the end of a very long surgery we’d dealt with a large number of patients and their families and were just about beginning to understand how all of those protocols worked in practice.

Going home that night it was clear to me that the next day would be much worse. Having finished my surgery at almost 8pm it was also clear that we needed a better system in place to cope. One that didn’t involve fitting these telephone consultations- involving up to 6 patients per call plus all the associated prescriptions and notification paperwork- in amongst the normal offerings of a busy surgery. What was needed was a dedicated telephone flu clinic with expertise in how to manage these cases and their contacts being rapidly acquired. And so began the first of my flu clinics.

The first thing that having a dedicated clinic did was take the pressure off of the receptionists who no longer felt overwhelmed. Calls were returned within 20 minutes and this alone, I suspect, helped reassure parents that the health system was up and working and would be there if needed. On this, the first full day of our local outbreak, we had been advised to treat all probable cases and all household or close contacts. By the second day we were asked to treat only high risk household contacts.

All of the children I’ve been involved with so far have had relatively mild symptoms: a fever of 38 or 39, being subdued, eating less, a cough, a runny nose, a sore throat, all improving significantly within 2 days. But I’ve also had high risk patients who haven’t been so well: a grandfather with asthma, wheezing and coughing up green phlegm, who needed antibiotics and a steroid inhaler in addition to his tamiflu; a mother with cardiac problems who was feeling very unwell with her flu symptoms; a sibling with chronic health problems who needed prophylaxis; a pregnant mother of a probable case in two minds about whether to take the relenza that by day 2 was being recommended for pregnant contacts or cases.

As a doctor it’s been a steep and interesting learning curve in which I’ve gone from just about understanding, in theory, how this is all supposed to work, from knowing, from experience, how to deliver good swine flu care from switchboard to consulting room, with assessing contacts and educating and reassuring being key tasks. There has also been an interesting line of thought emerging from both patients and health care professionals, the suggestion that it’s better to get this now, before it (maybe) mutates to something more virilent.

If you’ve got it already, like half the little ones from our neighborhood, and all is well, then I’d agree. But for other people, especially those who are high risk, I think that argument breaks down. This isn’t like chicken pox-ie get it when you’re young and it’s sure to be milder- because we don’t know how any one person will react. Of course it might be mild, is likely to be mild, but then again it might not, especially if you’ve got asthma or one of the other preexisting conditions that make you more vulnerable. And if you can manage not to get it for a few more months we should, hopefully, have a vaccine which will go first to those same high risk individuals. Hence giving tamiflu to not very ill children, not for them so much as for those around them who might not be so fortunate. And to their high risk contacts for the same reason.

Early days, time will tell and all that. Interesting how little is on the news anymore. Is it just that the story got old, or that the media heeded calls not to whip up panic, or that more important things have knocked swine flu off the news agenda? I suspect our local experience is being quietly repeated all around the country and that we’re all finding our own way to ¬†respond to our patients’ needs for help and reassurance. Hence my decision to share my experiences with you. Just in case today or tomorrow is your first day and you’re wondering what to do next.