11/11/2009 - 09:18

When the H1N1 flu hits home

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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On Saturday, October 24, President Barack Obama declared the H1N1 flu a national emergency. To date, more than 20,000 people have been hospitalized and more than 1,000 have died. Unfortunately, production of the H1N1 vaccine has been delayed and only 32 million doses have been shipped to health care providers--too few to have a widespread effect.

While social distancing and hand hygiene (i.e., frequent handwashing) can help reduce flu spread, the reality is that those strategies alone aren't enough to contain it. The other reality is that a majority of flu sufferers will have to be cared for at home by their loved ones and not necessarily doctors and nurses.

Unfortunately, during the current H1N1 flu crisis, evidence suggests that people don’t know how to take care of sick family members or themselves since they are unnecessarily swamping emergency rooms."

As I've written previously, the United States has projected a dire long-term nursing shortage. For example, a 2006 report by the Health Resources and Services Administration suggests there will be a shortage of more than a million nurses by 2020. Worse yet, demand for nursing care is expected to increase starting next year because of the aging baby boomer population.

As a result, most nursing care will be provided by families and friends. According to the National Family Caregivers Association, more than 50 million people already provide care to aged, chronically ill, or disabled family members or friends each year. Seventeen percent of these family caregivers provide 40 or more hours per week of care in addition to their other familial and professional duties.

Before the rise of modern medicine and the advent of antibiotics such care was the norm. Most families learned to provide basic nursing care for themselves at home. And this isn't an altogether bad thing. For good personal and public health, everyone should know how to take vital signs such as body temperature and respiratory rates. Taken together and at regular intervals, vital signs provide an important picture of a person's health over time.

Unfortunately, during the current H1N1 flu crisis, evidence suggests that people don't know how to take care of sick family members or themselves since they are unnecessarily swamping emergency rooms. (See "Health Region Urges Limit to ER Flu Visits," "'Walking Well' Flood Hospitals with--or without--Flu Symptoms," and "Local Hospitals Battle Swine Flu.") Clearly, if people knew basic nursing skills, the nation's health care system would be in better shape to help those who really do need medical attention. In other words, everyone is on the frontlines of this crisis, so it's best to be as well-prepared as possible.

Therefore, Americans need a tutorial in basic nursing--and especially those Americans who are parents since daycare centers and schools are ground zero for flu spread and other respiratory illnesses.

Keeping track of vital signs. Parents should record their children's baseline temperature, heart rate, respiratory rate, and weight in a notebook when their kids are healthy. That way, if their children become ill, they can compare those baseline vital signs to those taken at regular intervals during an illness. The same goes for adults.

Temperatures should be taken with a glass thermometer, as in my experience, digital thermometers aren't always as accurate or reliable. Glass thermometers are now available without mercury. For adults and kids alike, any temperature more than 100 degrees is considered a fever.

Heart rate can also be monitored via low tech means--e.g., by placing the index and middle fingers over the pulse site (neck, inside upper arm, wrist, groin, behind the knee, or top of the foot) and counting beats for 60 seconds (a watch with a second hand is needed), which provides the heart rate per minute. Infants have fast heart rates of between 100-160 beats per minute; anyone over the age of 10 should have a heart rate between 60-100 beats per minute.

Similarly, infants and young children breathe faster than adults--infants at about 40-60 breaths per minute and kids at somewhere between 12-30 times per minute. To measure the respiratory rate, merely count a breath as one rise and fall of the chest. Shallow breathing, gasping, wheezing, and coughing are warning signs that medical attention might be necessary.

To gauge a person's blood pressure without a stethoscope or blood pressure cuff have him or her lay down for a minute or so and then sit up. If he or she is dizzy and lightheaded within three minutes of being upright, there's a good chance their blood pressure is low.

Finally, an important note regarding hydration: Drinking fluids is far more important during an acute illness than eating. Although severe dehydration can accompany the flu, it can be overcome with basic measures such as sucking on ice chips and that old standard, chicken noodle soup.

Administering the appropriate medications. Only acetaminophen and ibuprofen should be given to children, teenagers, and young adults with the flu or any other viral illness. Aspirin should never be given to them because of the risk of Reye syndrome, a condition that causes brain and liver swelling that can prove fatal. As for prescription medications for the flu, antibiotics won't work--the flu is a virus, not a bacteria. The Centers for Disease Control and Prevention has guidelines and directions for the use of anti-viral drugs against influenza, especially by people at high risk for complications (children younger than two years old, pregnant women, and people with chronic medical conditions such as diabetes or asthma). To be effective, these medications must be started within two days of getting sick.

No amount of medication will make H1N1 less contagious. And since it's contagious at a distance of up to 6 feet, sick family members should be separated from the rest of their relatives to reduce the risk of transmission. In addition, one of the most effective ways to keep the flu virus from spreading is hygiene--clean hands, dishes, and linens.

Political lessons from the H1N1 outbreak. Most elected officials prefer to defer to medical and public health experts during a crisis such as H1N1. Such a strategy makes sense when outbreaks are limited, but when they begin to disrupt basic societal functions, political leaders must assert themselves. In my opinion, it was a mistake for President Obama not to communicate earlier to a frightened U.S. public. Moving forward, he could help quell public anxiety by making Washington's decision-making as transparent as possible and by providing frequent and honest flu crisis updates. False reassurances that "everything is under control" or "more vaccine will arrive soon" will only cost him further credibility. (See "Shortage of Vaccine Poses Political Test for Obama.")

At the local level, governors and mayors have a critical role in guaranteeing that state and local public health and medical professionals have the resources and support they need to coordinate vaccine supplies and deliveries as soon as they become available. For instance, political support might be needed to secure additional medical facilities, nursing personnel, and/or supplies for vaccination clinics.

All the while, public health educators, nurses, and physicians must do a better job of teaching the public about how to properly care for those who get sick with the flu. It's critical for everyone in the United States and the rest of the world to understand that the larger the population that gets sick, the greater the burden will be on health care facilities, which will place a greater burden on informal caregivers. While there are websites on home care available, these sites haven't received the press attention that they deserve. This information is particularly important for the millions of people without a private physician or health care provider. Information on proper home nursing should be seen as a public health service and could make a difference in alleviating overburdened emergency rooms and in saving lives.