To say I was surprised is an understatement. And yet, I’m a pediatric intensive care physician.
As a clinician, it’s easy for me to trace out the clinical course of Liza’s illness. The physiology of organ failure, mechanical ventilation and critical illness are familiar to me in the same way that your daily work is to you. It’s the human side that I still haven’t come to terms with. The part where you watch your sister die over the course of three long weeks while you stand helpless. The part where you listen to a physician tell your family that they are out of options. The part where you know that they are right and you realize that influenza is sometimes too much to handle, even with all our modern medicine.
That part is much harder to process.
Her symptoms started with fever, but progressed to vomiting after a few days. She went to the urgent care clinic twice over the course of a few days before ending up in the emergency department of the local hospital. She had begun to experience difficulty breathing, and the emergency physician noted that the oxygen saturation in her blood was very low. They put her on oxygen, and an x-ray revealed that both her lungs were filled with fluid. A condition that led to her being diagnosed with pneumonia. You see, your lungs are supposed to have air in them. They should look like sponges. Pneumonia is just the term we physicians use to describe the situation when fluid, infection, and inflammation fill those little air spaces in the sponge.
Pneumonia can come from viruses or bacteria. If your pneumonia is caused by a bacteria, you can get antibiotics to kill the bacteria. However, if your pneumonia is caused by a virus, like influenza, there is not much we can do but ride it out and wait for your own immune system to clear it. The simple fact is that we just don’t have very good medications for viruses. Tamiflu can be prescribed and it might slow down the virus, but it doesn’t kill it or stop it.
So, they did the only thing they really could do, and started her on IV Tamiflu. She was moved to the intensive care unit downtown, and within the next few hours she struggled to breathe and her oxygen saturations continued to fall. She had to be placed on a ventilator, and the hope was that her lungs would recover after a few days. After all, it was ‘just the flu’.
We never did get to speak with her again.
Mechanical ventilation works by using pressure to drive air into your lungs. The pressure forces fluid out of the air spaces and allows oxygen to diffuse into the blood. The ventilator does not make you better; it only keeps you alive while your body attempts to heal. As the flu virus raged on and as her body strove to fight the infection, her lungs became stiff and brittle, making it much harder to force air into them. The ventilator settings changed and even the ventilator itself was changed, but it quickly became clear that despite our technology and knowledge, Liza’s lung disease was progressing beyond the ability of modern medicine to support.
During this time I acted as medical interpreter to my family. “Why aren’t they doing more?” they would ask me as I watched her laboratory results change each day. An ICU truism is that the less you do to a patient, the more likely they are to get better. This level of medicine is a waiting game, knowing when to watch and wait, when to intervene, and knowing how to minimize the risk of making someone worse when you do need to intervene. Blood level low? Transfuse just enough blood, but not too often. Oxygen saturations low? Don’t get too aggressive with the ventilator.
Eventually the delicate, injured parts of the lungs blew apart, something called a pneumothorax. The ICU team promptly diagnosed the problem and treated it by placing a tube in her chest to drain the air. But at this point, the damage was so extensive that there wasn’t enough functioning lung left to support gas exchange. With her body now starving for oxygen, there was nothing left to do.
Liza died December 5, 2009 in Pittsburgh, Pennsylvania, surrounded by family.
I began my pediatric residency in 2005, and in the time since then I’ve seen too many cases like Liza’s. It’s true that the very young, the very old and those with chronic medical conditions (those deemed ‘medically fragile’) are at the highest risk for complications from influenza. Yet, every year I see a handful of previously healthy young people end up in my ICU on ventilators. Most of those who end up seeing me are unvaccinated, even in years when the vaccine is deemed less effective at preventing infection. Lower risk does not mean no risk.
It’s also true that many people who die from influenza have secondary complications such as bacterial superinfections, myocarditis (a viral infection of the heart itself that causes heart failure), sepsis (infection in the blood) or pulmonary embolism (throwing a blood clot into your lungs).
What’s important to understand is that none of these secondary problems would have occurred in the absence of influenza infection.
It’s not the fall that kills you, it’s the sudden stop at the end.
And finally I cannot stress enough how little we have in the way of treatment. Antiviral agents are in their infancy. Medical technology allows us to support and sometimes even temporarily replace failing organs, but ultimately we cannot reverse these processes of infection, inflammation and necrosis once they are set into motion. In fact, most vaccine preventable diseases have no effective treatment, which is why prevention through vaccination is so important. An ounce of prevention is worth ten thousand pounds of treatment, and a tiny fraction of an ounce of flu vaccine might have saved my sister’s life.
Liza never expected to get sick. Even after she got sick, she expected to be back at work in a few days. Throughout her hospital stay many well-meaning friends simply expected her to recover, saying it was ‘just the flu’. Even I poked fun at her for missing work.
What I never expected was to be on the family side of a flu death. It may have been ‘just the flu’ but in Liza’s case, and in thousands of other cases each year, ‘just the flu’ is enough to kill you.
I share my sister’s story in hopes that it will encourage others to vaccinate. Just remember, once a flu virus has infected your body, it’s too late to go back and get that vaccine. You may recover or you may not. Why take a chance. Take a moment to get vaccinated and you will have reduced your risk of getting sick in the first place.
Michael Northrop, M.D.
Pediatric Critical Care
Assistant Professor of Pediatrics
Director, PICU ECMO services
Vice Chair of Hospital Safety and Quality
Baylor College of Medicine
Children’s Hospital of San Antonio