When Stated Cause of Death Is Not in Alignment with Reality

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How Not to Report a Fatal Outcome

http://scienceblogs.com/effectmeasure/2009/07/swine_flu_how_not_to_report_a.php#m

We knew it had to happen sooner or later. The first health care worker (that we know of) in this pandemic, has died supposedly of "natural causes" which is to say that he had blood clots in his lungs. Yet, he was positive for swine flu, and yes, he did have viral pneumonia...

How often does a death certificate not reveal all of the factors that come into play to cause the early demise of a patient? We've all seen this before.

Now how about getting serious about providing PPE in all health care facilities including the places where we are most likely not to see them such nursing homes, assisted living, clinics and doctors' offices?

...there is a complete failure to examine the meaning of what was reported. Meaning in the most literal sense. What does it mean when someone who has swine flu dies of "natural causes"? This doctor had heart disease, high blood pressure and . . . viral pneumonia!. On the one hand we're told that a major risk factor for dying from swine flu is having an underlying medical condition. Like what? Heart disease and high blood pressure? And what does infection with the influenza virus cause in someone's lungs? How about viral pneumonia.

The egregiously bad reporting aside, there are some interesting scientific questions in this personal tragedy (this is the first health care worker I am aware of to die in the acute phase of a swine flu infection). A CDC MMWR Dispatch widely reported last week reported in 10 cases from a Michigan tertiary care facility that treated Acute Respiratory Distress Syndrome (ARDS) in 10 swine flu cases. There were two unusual features in this case series (which is not obviously representative of all severely ill swine flu victims but still of interest). One was the high proportion of very obese patients. In CDC lingo, Body Mass Index (BMI) from 25 to 30 is considered "overweight." Obesity is a BMI over 30. If someone has a BMI over 40, they are considered "morbidly obese" (if you want to know what your BMI is you can go to one of many online calculators, for example, here; you'll need to enter your height and weight). Nine of 10 were obese by these standards (BMI over 30), and 6 of the 10 were morbidly obese (BMI over 40), 4 of the 6 with BMIs over 50. I'm a person of average height (5'10"). To have a BMI of 50 I would need to weigh 350 pounds. The relationship of marked obesity has not been previously noted.

I don't know the weight of the doctor who died (his photo is head shot but he doesn't appear morbidly obese), so there is no indication that obesity is an additional risk factor here. So why am I bringing up this report? Because there was another unusual feature in these 10 intensive care patients. Half of them had pulmonary emboli (blood clots in the lung):

Pulmonary emboli are not known to be a common complication of ARDS or of sepsis syndrome, but both ARDS and sepsis represent hypercoagulable states. Pulmonary emboli were not noted in patients hospitalized with novel influenza A (H1N1) virus infection in Mexico. One clinical study did not identify any increased risk for pulmonary embolism with seasonal influenza virus infection. However, a report of two patients with rapidly progressive hypoxemia associated with influenza A (H3N2) virus infection noted that they received a diagnosis of acute pulmonary embolism. Clinicians providing care to patients with novel influenza A (H1N1) virus infection should be aware of the potential for patients with ARDS to develop a hypercoagulable state and for pulmonary emboli to cause severe complications, including fatal outcomes. (Morbidity and Mortality Weekly Reports, CDC [cites omitted])

The unfortunate doctor in this case probably died of his pulmonary emboli, so he becomes yet another data point associated swine flu associated ARDS. Whether pulmonary emboli went along with obesity in his case is thus of interest. I understand that these scientific issues are probably beyond the ken of most non specialist reporters, but one would think that the death of the first GP at a time when the role of GPs in treating swine flu is a matter of discussion and controversy in the UK would have merited more than perfunctory treatment. And to call it perfunctory is perhaps being generous.

The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

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How Not to Report a Fatal Outcome

http://scienceblogs.com/effectmeasure/2009/07/swine_flu_how_not_to_report_a.php#m

We knew it had to happen sooner or later. The first health care worker (that we know of) in this pandemic, has died supposedly of "natural causes" which is to say that he had blood clots in his lungs. Yet, he was positive for swine flu, and yes, he did have viral pneumonia...

How often does a death certificate not reveal all of the factors that come into play to cause the early demise of a patient? We've all seen this before.

Now how about getting serious about providing PPE in all health care facilities including the places where we are most likely not to see them such nursing homes, assisted living, clinics and doctors' offices?

The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

This is really irksome. It bothers me that the old time GPs in 1918 would have called this what it is, a flu death. It raises the question, "Is someone applying pressure for political and economic reasons to play this thing down?" Shame, shame, shame on them, how can this thing possible be battled if the facts are not clear. This is one of the more important things you have posted

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Specializes in ICU, Telemetry.

I don't know about what's going on now, but when Hurricane Andrew hit Miami, the "official" death toll was like 56, 57, something like that. The son of a coworker was in the national guard, and he told her he saw a refrig. warehouse that had hundreds of bodies in it -- homeless, illegals, old folks with no family to come looking for them -- he saw it, because he guarded it. And there were pages and pages and pages of "Looking for..." or "Call home..." adds in the newspapers for weeks and weeks. Not the kind of thing that goes on when you've got less than 100 dead. South Florida is all about tourism, and nobody would want to go visit "Dead People R Us." So if there was no ID, there was no body....

Remember the scene in "The Stand" where the Nick figures out that the news is being altered (in his case, there's no video from games and such being talked about). I have a feeling we're all going to have our own, personal "Nick" moment, sometime this fall...

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Specializes in Too many to list.

Telling the Truth vs Managing the Truth

http://www.flutrackers.com/forum/showpost.php?p=266873&postcount=4

Kudos, Dr. Thornton! This is how all pandemic communication should be.

From my perspective in behavioral health this is the resource I will promote:

Quote:

The second most important resource is communication. Getting and sustaining

compliance – changing behavior and keeping it changed – requires winning public trust.

Gaining trust requires explaining in detail why each recommendation was made and why others were not. It also requires, when decisions are made, taking the offense through a massive campaign to dominate all media, including the internet. And if the situation becomes severe, experience from 1918 to SARS demonstrates that only full and candid disclosure of the truth will contain panic. This author is wary of the term “risk communication.” It implies management of information. You do not manage the truth.You tell the truth. The most significant deficiency I have seen in the communications arena is using one message for all circumstances eg "the person died with pre-exisitng medical conditions," and "prevent getting flu by staying home when sick."

The authorities clearly are trying to get people to remain calm, wash their hands and to stay home when sick. However, giving the same message to all people in all circumstances does not acheive a unform behavioral response. People will behave according to their own risk assessment with the information they have. Some people prepare for a storm 3 days in advance, others when the storm is 3 hours away. Thus a general storm warning is insufficient for the public to prepare for the pandemic. People in affected communities need more details in order to make their own risk assessment and to adjust their behaviors.

Joe Thornton MD, psychiatrist

__________________

All epidemics are behavioral. JT

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Specializes in Too many to list.

Swine Flu Did Contribute to GP's Death

http://www.dunstabletoday.co.uk/dunstable-news/Swine-flu-did-contribute-to.5475581.jp

Swine flu did play a significant role in the death of a popular Dunstable GP, health authority bosses say.

Following the death of Dr Michael Day, there was speculation among the national media that his death had been caused to underlying health issues.

Dr Day, 64, who had worked at the Priory Gardens Health Centre for 35 years, had tested positive for the H1N1 virus following his death at the Luton & Dunstable Hospital on July 11.

A post-mortem examination last Tuesday ruled that Dr Day died from natural causes and national newspapers subsequently reported he died from further health complications, including a blood clot on the lungs.

A statement released by NHS Bedfordshire on Friday said: "The final coroner's report following the post-mortem into Dr Day's death has confirmed that swine flu was a significant factor in his death."

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